Provider Demographics
NPI:1992243992
Name:YOUTH VILLAGES
Entity type:Organization
Organization Name:YOUTH VILLAGES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ER DIVERSION SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DAINA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:TAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, QHMP
Authorized Official - Phone:541-513-4998
Mailing Address - Street 1:12945 SW HAWKS BEARD ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-1956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2507 CHRISTIE DR
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034
Practice Address - Country:US
Practice Address - Phone:503-635-3416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORM6979261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health