Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 14-CRM-024 | OR |
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | T-20-391 | OR |
NPI | 1003325200 |
---|---|
Provider Name | Ted Woodruff |
First Address | Baker City, OR 97814-1340 |
Second Address | Baker City, OR 97814-1340 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2017 |
Last Update Date | 06/07/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
14-CRM-024 | MHACBO CRM (01) | OR |
500609571 | (05) | OR |