Provider Demographics
NPI:1790568582
Name:DAVIS, HEATHER KATHLEEN (CADC-1 #25-04-11458)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:KATHLEEN
Last Name:DAVIS
Suffix:
Gender:
Credentials:CADC-1 #25-04-11458
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:KATHLEEN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CHW/THW #108169
Mailing Address - Street 1:310 NW 5TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-4849
Mailing Address - Country:US
Mailing Address - Phone:541-286-4010
Mailing Address - Fax:541-286-4011
Practice Address - Street 1:310 NW 5TH ST STE 101
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4849
Practice Address - Country:US
Practice Address - Phone:541-286-4010
Practice Address - Fax:541-286-4011
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR172V00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker