Provider Demographics
NPI:1285989822
Name:MIDSTREAM
Entity type:Organization
Organization Name:MIDSTREAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:CROWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-715-0910
Mailing Address - Street 1:1020 SW TAYLOR ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2543
Mailing Address - Country:US
Mailing Address - Phone:503-715-0910
Mailing Address - Fax:503-715-0911
Practice Address - Street 1:1020 SW TAYLOR ST
Practice Address - Street 2:SUITE 400
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2543
Practice Address - Country:US
Practice Address - Phone:503-715-0910
Practice Address - Fax:503-715-0911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL57211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500649487Medicaid
ORR165424Medicare PIN