MEDICARE: REACHING IN SERVING KIDS

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	06-R-06	OTHER	OR	CERTIFIED ALCOHOL AND DRUG COUNSELOR II

General Provider Information

NPI Number	:	1639430747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REACHING IN SERVING KIDS

Provider Business Mailing Address
First Line	:	4134 N VANCOUVER AVE
Second Line	:	SUITE 303C
City	:	PORTLAND
State	:	OR
Zip	:	97217-2900
Country	:	US
Telephone Number	:	503-593-7764
Fax Number	:	503-249-2047

Provider Business Practice Location Address
First Line	:	4134 N VANCOUVER AVE
Second Line	:	SUITE 303C
City	:	PORTLAND
State	:	OR
Zip	:	97217-2900
Country	:	US
Telephone Number	:	503-593-7764
Fax Number	:	503-249-2047

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. LEONARD N/A CLARK SR.
Credential	:	CADC II
Telephone Number	:	503-593-7764

Provider Enumeration Date	:	06/05/2012
Last Update Date	:	06/05/2012

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Directions to “REACHING IN SERVING KIDS ” Practice Location

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