Provider Demographics
NPI:1346881778
Name:THAYER, EVAN MICHAEL
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:MICHAEL
Last Name:THAYER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13050 NW CORNELL RD APT 3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5855
Mailing Address - Country:US
Mailing Address - Phone:503-476-2905
Mailing Address - Fax:
Practice Address - Street 1:12655 SW CENTER ST STE 100
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-1600
Practice Address - Country:US
Practice Address - Phone:503-828-3402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health