MEDICARE: BRADLEY JOSEPH OSBORN CAS, CADCII, SUDP

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	CP61335275	WA
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	6654	CO
3	101YA0400X	Addiction (Substance Use Disorder) Counselor	19-R-02	OR
4	101YM0800X	Mental Health Counselor	22-QMHA-I-003318	OR

General Provider Information

NPI Number	:	1457604266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY JOSEPH OSBORN CAS, CADCII, SUDP

Provider Business Mailing Address
First Line	:	4333 NE 113TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97220-2449
Country	:	US
Telephone Number	:	970-319-8001
Fax Number	:

Provider Business Practice Location Address
First Line	:	4333 NE 113TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97220-2449
Country	:	US
Telephone Number	:	970-319-8001
Fax Number	:

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

Provider Enumeration Date	:	10/17/2012
Last Update Date	:	10/30/2024

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