Healthcare Provider Details

I. General information

NPI: 1679013601
Provider Name (Legal Business Name): COTRELL MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2017
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7759 SE 72ND AVE
PORTLAND OR
97206-7921
US

IV. Provider business mailing address

7759 SE 72ND AVE
PORTLAND OR
97206-7921
US

V. Phone/Fax

Practice location:
  • Phone: 503-788-4500
  • Fax:
Mailing address:
  • Phone: 503-788-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: