Healthcare Provider Details

I. General information

NPI: 1174086912
Provider Name (Legal Business Name): OLIVIA CUDDEFORD, BAI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18765 SW BOONES FERRY RD STE 100
TUALATIN OR
97062-8607
US

IV. Provider business mailing address

18765 SW BOONES FERRY RD STE 100
TUALATIN OR
97062-8607
US

V. Phone/Fax

Practice location:
  • Phone: 503-612-1000
  • Fax:
Mailing address:
  • Phone: 503-612-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number10204612
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: