Provider Demographics
NPI:1457707077
Name:OLIVER-PALMQUIST, SAMUEL STAN
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:STAN
Last Name:OLIVER-PALMQUIST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2645 PORTLAND RD NE STE 120
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-0200
Mailing Address - Country:US
Mailing Address - Phone:503-390-5637
Mailing Address - Fax:
Practice Address - Street 1:2645 PORTLAND RD NE STE 120
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0200
Practice Address - Country:US
Practice Address - Phone:503-390-5637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT1592101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional