MEDICARE: FREDERICK DOUGLASS STATEN PH.D.,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	101YP2500X	Professional Counselor	LH60296096	WA
2	101YP2500X	Professional Counselor	C4765	OR
3	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1417216730
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREDERICK DOUGLASS STATEN PH.D.,LPC, CADC III

Provider Business Mailing Address
First Line	:	PO BOX 8459
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97207-8459
Country	:	US
Telephone Number	:	503-230-9654
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	:	503-244-4500
Fax Number	:	503-244-2008

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

Provider Enumeration Date	:	05/07/2012
Last Update Date	:	03/13/2026

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