Healthcare Provider Details

I. General information

NPI: 1760501076
Provider Name (Legal Business Name): PATTI DAVIS CADC11
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 NE KILLINGSWORTH ST
PORTLAND OR
97218-1404
US

IV. Provider business mailing address

906 SW 14TH ST
TROUTDALE OR
97060-1419
US

V. Phone/Fax

Practice location:
  • Phone: 503-535-1150
  • Fax: 503-528-0800
Mailing address:
  • Phone: 503-667-2997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: