Provider Demographics
NPI:1548894868
Name:SURBAN, CORRINE GAIL (RN, CADC I)
Entity type:Individual
Prefix:
First Name:CORRINE
Middle Name:GAIL
Last Name:SURBAN
Suffix:
Gender:F
Credentials:RN, CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10101 SW BARBUR BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5915
Mailing Address - Country:US
Mailing Address - Phone:503-245-6262
Mailing Address - Fax:503-245-6263
Practice Address - Street 1:10101 SW BARBUR BLVD STE 101
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-5915
Practice Address - Country:US
Practice Address - Phone:503-245-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-25
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20-01-34101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)