Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 11-12-48 | OR |
NPI | 1003286840 |
---|---|
Provider Name | Albert Martineau |
First Address | Grand Ronde, OR 97347-0338 |
Second Address | Grand Ronde, OR 97347-9712 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/10/2015 |
Last Update Date | 06/10/2015 |