Healthcare Provider Details

I. General information

NPI: 1902208499
Provider Name (Legal Business Name): FELESIA OTIS CADC II
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3910 SE STARK ST
PORTLAND OR
97214-3241
US

IV. Provider business mailing address

3910 SE STARK ST
PORTLAND OR
97214-3241
US

V. Phone/Fax

Practice location:
  • Phone: 503-595-3477
  • Fax:
Mailing address:
  • Phone: 503-595-3477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number06-07-64
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: