Healthcare Provider Details

I. General information

NPI: 1639826266
Provider Name (Legal Business Name): JUSTIN D BUCHANAN AGS, CADC-II, QMHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2022
Last Update Date: 10/29/2026
Certification Date: 10/29/2026
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: 971-533-1369
  • Fax: 503-771-2436
Mailing address:
  • Phone: 971-533-1369
  • Fax: 503-771-2436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25-01-20521
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number25-QMHA-R-7810
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: