Provider Demographics
NPI:1174892301
Name:POLK COUNTY MENTAL HEALTH
Entity type:Organization
Organization Name:POLK COUNTY MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESCRIBER SUPPORT SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DARA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LURAS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:503-623-9289
Mailing Address - Street 1:182 SW ACADEMY ST
Mailing Address - Street 2:SUITE304
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1922
Mailing Address - Country:US
Mailing Address - Phone:503-623-9289
Mailing Address - Fax:503-831-1726
Practice Address - Street 1:182 SW ACADEMY ST
Practice Address - Street 2:SUITE304
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1922
Practice Address - Country:US
Practice Address - Phone:503-623-9289
Practice Address - Fax:503-831-1726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201130510LPN261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)