Provider Demographics
NPI:1063848687
Name:VERDEGUEZ, RICARDO ANTONIO (CADC I)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:ANTONIO
Last Name:VERDEGUEZ
Suffix:
Gender:M
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 NE MLK BLVD APT 309
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-3494
Mailing Address - Country:US
Mailing Address - Phone:503-546-9975
Mailing Address - Fax:503-546-9976
Practice Address - Street 1:1949 SE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1303
Practice Address - Country:US
Practice Address - Phone:503-546-9975
Practice Address - Fax:503-546-9976
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15- P-02101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator