Provider Demographics
NPI:1417991258
Name:PENDLETON ACADMIES
Entity type:Organization
Organization Name:PENDLETON ACADMIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERIM EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:P.
Authorized Official - Middle Name:TERRY
Authorized Official - Last Name:EDVALSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-966-7810
Mailing Address - Street 1:622 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-4598
Mailing Address - Country:US
Mailing Address - Phone:541-276-0057
Mailing Address - Fax:541-276-1704
Practice Address - Street 1:622 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-4598
Practice Address - Country:US
Practice Address - Phone:541-276-0057
Practice Address - Fax:541-276-1704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X, 103T00000X, 103TB0200X, 103TC1900X, 251B00000X, 251S00000X, 320600000X, 320800000X, 322D00000X, 385HR2055X
103TC0700X, 103TC2200X, 320900000X, 323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed ChildrenGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Multi-Specialty
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment FacilityGroup - Multi-Specialty
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR312056Medicaid
ORS20475Medicaid
OR312041Medicaid
OR312048Medicaid
OR313437Medicaid
ORPCG023Medicaid
OR312064Medicaid
OR313205Medicaid
OR182229Medicaid
OR312040Medicaid