Provider Demographics
NPI:1851715866
Name:HAFEZ-TRIEM, RUKSHANA
Entity Type:Individual
Prefix:
First Name:RUKSHANA
Middle Name:
Last Name:HAFEZ-TRIEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 NE DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-4716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:617 NE DAVIS ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-4716
Practice Address - Country:US
Practice Address - Phone:503-472-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-11
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1326056433Medicaid