Healthcare Provider Details

I. General information

NPI: 1669161014
Provider Name (Legal Business Name): SAMUEL ALLEN TUCKWIN CADC-R/CSWA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SAM ALLEN TUCKWIN CADC-R/CSWA

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 NE 2ND ST
GRESHAM OR
97030-7514
US

IV. Provider business mailing address

211 SE CARUTHERS ST
PORTLAND OR
97214-4502
US

V. Phone/Fax

Practice location:
  • Phone: 971-274-3757
  • Fax: 503-912-5740
Mailing address:
  • Phone: 503-224-1044
  • Fax: 971-260-0355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-24-3972
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSC61570839
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberA14705
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500819391
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: