Healthcare Provider Details

I. General information

NPI: 1073443107
Provider Name (Legal Business Name): PRESTON FABRE PWS, CRM II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 NW DIVISION ST
GRESHAM OR
97030-5523
US

IV. Provider business mailing address

211 SE CARUTHERS ST
PORTLAND OR
97214-4502
US

V. Phone/Fax

Practice location:
  • Phone: 503-231-2641
  • Fax:
Mailing address:
  • Phone: 971-217-9008
  • Fax: 971-260-0355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number108843
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25-CRM-II-0344
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: