MEDICARE: BROADER PATH THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1184558033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADER PATH THERAPY LLC

Provider Business Mailing Address
First Line	:	5441 S MACADAM AVE STE R
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97239-3822
Country	:	US
Telephone Number	:	503-753-0243
Fax Number	:

Provider Business Practice Location Address
First Line	:	6904 N KNOWLES AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97217-5117
Country	:	US
Telephone Number	:	503-753-0243
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	MR. MATTHEW LOVETT TALLMAN
Credential	:	LCSW
Telephone Number	:	503-753-0243

Provider Enumeration Date	:	06/08/2026
Last Update Date	:	06/08/2026

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Directions to “BROADER PATH THERAPY LLC ” Practice Location

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