=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285036590
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENISE WASHBURN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2014
-----------------------------------------------------
Last Update Date | 12/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11035 NE SANDY BLVD
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97220-2553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-258-4200
-----------------------------------------------------
Fax | 503-230-4448
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11035 NE SANDY BLVD
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97220-2553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-258-4200
-----------------------------------------------------
Fax | 503-230-4448
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number | 0001073
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------