Healthcare Provider Details

I. General information

NPI: 1548678097
Provider Name (Legal Business Name): JAMES LEE BRISCOE CADC IU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2014
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 SE 82ND DR. BLDG. C
GLADSTONE OR
97027
US

IV. Provider business mailing address

PO BOX 82819
PORTLAND OR
97282-0819
US

V. Phone/Fax

Practice location:
  • Phone: 503-659-5515
  • Fax: 503-594-8193
Mailing address:
  • Phone: 503-233-5409
  • Fax: 503-233-2694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11-03-52U
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: