Healthcare Provider Details

I. General information

NPI: 1700607686
Provider Name (Legal Business Name): ERIC WADE LYSNE CADC-R, CRM1
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10564 SE WASHINGTON ST
PORTLAND OR
97216-2809
US

IV. Provider business mailing address

10564 SE WASHINGTON ST
PORTLAND OR
97216-2809
US

V. Phone/Fax

Practice location:
  • Phone: 503-228-9229
  • Fax:
Mailing address:
  • Phone: 503-228-9229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-24-3638
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: