Healthcare Provider Details

I. General information

NPI: 1134584527
Provider Name (Legal Business Name): TARA HOLLY RAYBURN CADCI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2015
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1722 NW RALEIGH ST SPC 304
PORTLAND OR
97209-1752
US

IV. Provider business mailing address

1722 NW RALEIGH ST SPC 304
PORTLAND OR
97209-1752
US

V. Phone/Fax

Practice location:
  • Phone: 971-645-0148
  • Fax:
Mailing address:
  • Phone: 503-325-2067
  • Fax: 503-325-2153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20-10-06
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number21-QMHP-R-0664
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWIA.SC.61162847
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number15-11-08
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: