Provider Demographics
NPI:1770603532
Name:POLK COUNTY MENTAL HEALTH
Entity type:Organization
Organization Name:POLK COUNTY MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH COUNSELOR I
Authorized Official - Prefix:
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-623-9289
Mailing Address - Street 1:182 SW ACADEMY ST STE 304
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1900
Mailing Address - Country:US
Mailing Address - Phone:503-851-6737
Mailing Address - Fax:
Practice Address - Street 1:182 SW ACADEMY ST STE 304
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1900
Practice Address - Country:US
Practice Address - Phone:503-623-9289
Practice Address - Fax:503-831-1726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR00-07-15261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR00-07-15OtherCADC I