Healthcare Provider Details

I. General information

NPI: 1497393425
Provider Name (Legal Business Name): MR. BRADLEY PAUL ROAN EAGLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2019
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 13TH ST
BAKER CITY OR
97814-1340
US

IV. Provider business mailing address

3425 13TH ST
BAKER CITY OR
97814-1340
US

V. Phone/Fax

Practice location:
  • Phone: 605-516-0083
  • Fax:
Mailing address:
  • Phone: 541-523-7400
  • Fax: 541-523-4927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-20-486
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCADC-RT-20-486
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number20-QMHA-R-0842
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number21-CRM-411
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: