Provider Demographics
NPI:1881832095
Name:INTEGRATED YOUTHCARE, LLC
Entity Type:Organization
Organization Name:INTEGRATED YOUTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEBE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-230-1630
Mailing Address - Street 1:673 NW JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-4832
Mailing Address - Country:US
Mailing Address - Phone:541-230-1630
Mailing Address - Fax:
Practice Address - Street 1:673 NW JACKSON AVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4832
Practice Address - Country:US
Practice Address - Phone:541-230-1630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-26
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2485101YM0800X
ORC2422101YM0800X
ORL44041041C0700X
OR200950078NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1245386440OtherNPI
OR1164568895OtherNPI
OR1881832095OtherNPI
OR1144439019OtherNPI
OR1285862938OtherNPI