Healthcare Provider Details

I. General information

NPI: 1346881778
Provider Name (Legal Business Name): EVAN MICHAEL THAYER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12655 SW CENTER ST STE 100
BEAVERTON OR
97005-1600
US

IV. Provider business mailing address

16055 SW WALKER RD # 443
BEAVERTON OR
97006-4942
US

V. Phone/Fax

Practice location:
  • Phone: 503-828-3402
  • Fax:
Mailing address:
  • Phone: 971-224-6357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL30018
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: