=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336656982
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRANSFORMATIVE PATHWAYS PDX
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2018
-----------------------------------------------------
Last Update Date | 01/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2951 NW DIVISION ST
-----------------------------------------------------
City | GRESHAM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97030-5292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-401-3784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2951 NW DIVISION ST
-----------------------------------------------------
City | GRESHAM
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97030-5292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRANDON HARDAWAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 971-401-3784
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | A4231
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------