Provider Demographics
NPI:1598395824
Name:ULTREIA COUNSELING SERVICES, LLC
Entity type:Organization
Organization Name:ULTREIA COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALMA
Authorized Official - Middle Name:P
Authorized Official - Last Name:NECHI-GARIBAY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-569-3183
Mailing Address - Street 1:2855 WIGGLES CT NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-7465
Mailing Address - Country:US
Mailing Address - Phone:503-569-3183
Mailing Address - Fax:
Practice Address - Street 1:2105 LIBERTY ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-8353
Practice Address - Country:US
Practice Address - Phone:503-569-3183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-26
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1790064301Medicaid