Provider Demographics
NPI:1992196810
Name:ALEY, SAMUEL HASKIN (MS)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:HASKIN
Last Name:ALEY
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4301
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0520
Mailing Address - Country:US
Mailing Address - Phone:541-260-2106
Mailing Address - Fax:
Practice Address - Street 1:678 14TH CT
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-4469
Practice Address - Country:US
Practice Address - Phone:541-260-2106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-13
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR70492103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3259310003OtherOREGON VOCATIONAL REAHABILITATION VENDOR NUMBER