Provider Demographics
NPI:1417216730
Name:STATEN, FREDERICK DOUGLASS (PHD,LPC,CRC,CADC)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:DOUGLASS
Last Name:STATEN
Suffix:
Gender:M
Credentials:PHD,LPC,CRC,CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8459
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-8459
Mailing Address - Country:US
Mailing Address - Phone:503-230-9654
Mailing Address - Fax:
Practice Address - Street 1:2415 SE 43RD AVE STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1666
Practice Address - Country:US
Practice Address - Phone:503-230-9654
Practice Address - Fax:503-236-7166
Is Sole Proprietor?:No
Enumeration Date:2012-05-07
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
ORC2994101YP2500X
WALH60296096101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)