Provider Demographics
NPI:1407249063
Name:VINEYARD, TAYLOR (CADC, QMHP)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:VINEYARD
Suffix:
Gender:M
Credentials:CADC, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 E. BURNSIDE ST.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214
Mailing Address - Country:US
Mailing Address - Phone:503-239-8400
Mailing Address - Fax:503-269-8407
Practice Address - Street 1:1427 SE 182ND AVE.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233
Practice Address - Country:US
Practice Address - Phone:503-761-6006
Practice Address - Fax:503-761-1434
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OR390200000X
WAMC60593925101YM0800X
OR15-07-2-1101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health