Healthcare Provider Details

I. General information

NPI: 1376391904
Provider Name (Legal Business Name): BRANDON WINWARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2024
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 NE BURNSIDE RD STE 701
GRESHAM OR
97030-5770
US

IV. Provider business mailing address

10117 SE SUNNYSIDE RD # F1217
CLACKAMAS OR
97015-7708
US

V. Phone/Fax

Practice location:
  • Phone: 503-740-1971
  • Fax: 503-771-2436
Mailing address:
  • Phone: 503-740-1971
  • Fax: 503-771-2436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-25-5276
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number22-CRM-1078
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: