Healthcare Provider Details

I. General information

NPI: 1679056204
Provider Name (Legal Business Name): MATTHEW BAILEY MSW, LSW, CPRP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 NE DIVISION ST
GRESHAM OR
97030-4617
US

IV. Provider business mailing address

5035 FOOTHILLS RD APT J
LAKE OSWEGO OR
97034-4125
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-3808
  • Fax:
Mailing address:
  • Phone: 814-602-8140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: