MEDICARE: MYAH ROWAN SOVA CADC R

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	101YM0800X	Mental Health Counselor	26-QMHA-R-8530	OR
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	26-04-11875	OR
3	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1376217711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYAH ROWAN SOVA CADC R

Provider Business Mailing Address
First Line	:	12110 E BURNSIDE ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97216-3792
Country	:	US
Telephone Number	:	503-547-7320
Fax Number	:

Provider Business Practice Location Address
First Line	:	10920 SW BARBUR BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97219-8600
Country	:	US
Telephone Number	:	541-687-1110
Fax Number	:

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

Provider Enumeration Date	:	08/08/2021
Last Update Date	:	06/01/2026

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