Provider Demographics
| NPI: | 1417991258 |
|---|---|
| Name: | PENDLETON ACADMIES |
| Entity type: | Organization |
| Organization Name: | PENDLETON ACADMIES |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | INTERIM EXECUTIVE DIRECTOR |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | P. |
| Authorized Official - Middle Name: | TERRY |
| Authorized Official - Last Name: | EDVALSON |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 541-966-7810 |
| Mailing Address - Street 1: | 622 AIRPORT RD |
| Mailing Address - Street 2: | |
| Mailing Address - City: | PENDLETON |
| Mailing Address - State: | OR |
| Mailing Address - Zip Code: | 97801-4598 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 541-276-0057 |
| Mailing Address - Fax: | 541-276-1704 |
| Practice Address - Street 1: | 622 AIRPORT RD |
| Practice Address - Street 2: | |
| Practice Address - City: | PENDLETON |
| Practice Address - State: | OR |
| Practice Address - Zip Code: | 97801-4598 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 541-276-0057 |
| Practice Address - Fax: | 541-276-1704 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-06-15 |
| Last Update Date: | 2008-11-21 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| OR | 385HR2055X, 320600000X, 320800000X, 251S00000X, 251B00000X, 101YM0800X, 103T00000X, 103TB0200X, 103TC1900X, 322D00000X | |
| 323P00000X, 320900000X, 103TC0700X, 103TC2200X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 322D00000X | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | ||
| No | 385HR2055X | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child | Group - Multi-Specialty |
| No | 320600000X | Residential Treatment Facilities | Residential Treatment Facility, Intellectual and/or Developmental Disabilities | Group - Multi-Specialty | |
| No | 320800000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | Group - Multi-Specialty | |
| No | 251S00000X | Agencies | Community/Behavioral Health | Group - Multi-Specialty | |
| No | 251B00000X | Agencies | Case Management | Group - Multi-Specialty | |
| No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Multi-Specialty |
| No | 323P00000X | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | ||
| No | 320900000X | Residential Treatment Facilities | Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities | ||
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
| No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling | Group - Multi-Specialty |
| No | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| OR | 312056 | Medicaid | |
| OR | S20475 | Medicaid | |
| OR | 312041 | Medicaid | |
| OR | 312048 | Medicaid | |
| OR | 313437 | Medicaid | |
| OR | PCG023 | Medicaid | |
| OR | 312064 | Medicaid | |
| OR | 313205 | Medicaid | |
| OR | 182229 | Medicaid | |
| OR | 312040 | Medicaid |
