MEDICARE: MICHAEL DAVID RAZAVI MPH, CADC I, PRC,

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	11-09-48	OR
2	175T00000X	Peer Specialist	15-PRC-004	OR

General Provider Information

NPI Number	:	1760850549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL DAVID RAZAVI MPH, CADC I, PRC,

Provider Business Mailing Address
First Line	:	2054 N VANCOUVER AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97227-1917
Country	:	US
Telephone Number	:	503-231-8164
Fax Number	:

Provider Business Practice Location Address
First Line	:	2054 N VANCOUVER AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97227-1917
Country	:	US
Telephone Number	:	503-231-8164
Fax Number	:

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

Provider Enumeration Date	:	09/09/2015
Last Update Date	:	09/09/2015

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