Healthcare Provider Details

I. General information

NPI: 1316879554
Provider Name (Legal Business Name): TRISTAN KACZMAREK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10700 SW BEAVERTON HILLSDALE HWY STE 546
BEAVERTON OR
97005-4739
US

IV. Provider business mailing address

6875 SW NYBERG ST APT L104
TUALATIN OR
97062-8245
US

V. Phone/Fax

Practice location:
  • Phone: 971-459-0909
  • Fax:
Mailing address:
  • Phone: 541-408-0518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: