MEDICARE: DANIEL WAYNE BERRYMAN

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	18-12-13	OTHER	OR	CADC I

General Provider Information

NPI Number	:	1285134593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL WAYNE BERRYMAN

Provider Business Mailing Address
First Line	:	3610 NE 82ND AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97220-5182
Country	:	US
Telephone Number	:	503-408-9585
Fax Number	:	503-408-9456

Provider Business Practice Location Address
First Line	:	3610 NE 82ND AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97220-5182
Country	:	US
Telephone Number	:	503-408-9585
Fax Number	:	503-208-2596

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2018
Last Update Date	:	05/29/2019

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