Provider Demographics
NPI:1063757250
Name:CREEKSIDE COUNSELING, INC
Entity type:Organization
Organization Name:CREEKSIDE COUNSELING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MANAGER/ INSURANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLEJA
Authorized Official - Suffix:
Authorized Official - Credentials:BS, CADC 1
Authorized Official - Phone:503-371-4160
Mailing Address - Street 1:2586 12TH PL SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302
Mailing Address - Country:US
Mailing Address - Phone:503-371-4160
Mailing Address - Fax:
Practice Address - Street 1:2586 12TH PL SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2536
Practice Address - Country:US
Practice Address - Phone:503-371-4160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR08-03-04251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health