MEDICARE: DEVIN JOHN MCENRY CRM, BS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist	17-CRM-165	OR

General Provider Information

NPI Number	:	1578071205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVIN JOHN MCENRY CRM, BS

Provider Business Mailing Address
First Line	:	5266 SE 74TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-5211
Country	:	US
Telephone Number	:	360-600-7674
Fax Number	:

Provider Business Practice Location Address
First Line	:	7916 SE FOSTER RD STE 201
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-4289
Country	:	US
Telephone Number	:	971-344-6185
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2018
Last Update Date	:	01/16/2018

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