Provider Demographics
NPI:1083078083
Name:TALLMAN, MATTHEW LOVETT (CRM)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:LOVETT
Last Name:TALLMAN
Suffix:
Gender:M
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 NE 122ND AVE STE A200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-2083
Mailing Address - Country:US
Mailing Address - Phone:503-594-4766
Mailing Address - Fax:
Practice Address - Street 1:1122 NE 122ND AVE STE A200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2083
Practice Address - Country:US
Practice Address - Phone:503-594-4766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-06
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15CRM146101YA0400X
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)