Healthcare Provider Details

I. General information

NPI: 1184218562
Provider Name (Legal Business Name): DEREK MIRES CRM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2021
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 SE WASHINGTON ST
HILLSBORO OR
97123-4230
US

IV. Provider business mailing address

1027 E BURNSIDE ST
PORTLAND OR
97214-1328
US

V. Phone/Fax

Practice location:
  • Phone: 503-648-0753
  • Fax:
Mailing address:
  • Phone: 503-239-8400
  • Fax: 503-239-8407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: