Provider Demographics
NPI:1205995198
Name:SALAS, OCTAVIANO (CDP)
Entity type:Individual
Prefix:
First Name:OCTAVIANO
Middle Name:
Last Name:SALAS
Suffix:
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:OCTAVIANO
Other - Middle Name:
Other - Last Name:SALAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CDP
Mailing Address - Street 1:PO BOX 1323
Mailing Address - Street 2:515 W COURT ST
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301
Mailing Address - Country:US
Mailing Address - Phone:509-547-2204
Mailing Address - Fax:509-542-8836
Practice Address - Street 1:720 W COURT ST
Practice Address - Street 2:#8
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301
Practice Address - Country:US
Practice Address - Phone:509-545-6506
Practice Address - Fax:509-546-0520
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00001766101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)