Provider Demographics
NPI:1548636079
Name:PROFESSIONAL THERAPUETIC COMMUNITY NETWORK
Entity type:Organization
Organization Name:PROFESSIONAL THERAPUETIC COMMUNITY NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JESSSE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSCCSOFT
Authorized Official - Phone:503-391-7175
Mailing Address - Street 1:2905 RIVER RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-9754
Mailing Address - Country:US
Mailing Address - Phone:503-391-7175
Mailing Address - Fax:
Practice Address - Street 1:2905 RIVER RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-9754
Practice Address - Country:US
Practice Address - Phone:503-391-7175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500657056Medicaid