MEDICARE: MR. SEAN STRADLEY LPC CADC III

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	16-06-25	OR
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	CP60484457	WA
3	101YP2500X	Professional Counselor	C5136	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386064764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SEAN STRADLEY LPC CADC III

Provider Business Mailing Address
First Line	:	PO BOX 26
Second Line	:
City	:	REDMOND
State	:	OR
Zip	:	97756-0002
Country	:	US
Telephone Number	:	503-729-0777
Fax Number	:

Provider Business Practice Location Address
First Line	:	593 NW YORK DR
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97703-7264
Country	:	US
Telephone Number	:	541-728-3325
Fax Number	:

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

Provider Enumeration Date	:	04/23/2014
Last Update Date	:	10/16/2019

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