Provider Demographics
NPI:1467871939
Name:KIRBY, ROGER (CADC II)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:KIRBY
Suffix:
Gender:M
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 SW CEDAR HILLS BLVD STE 170
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2020
Mailing Address - Country:US
Mailing Address - Phone:503-626-1800
Mailing Address - Fax:
Practice Address - Street 1:3800 SW CEDAR HILLS BLVD STE 170
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2020
Practice Address - Country:US
Practice Address - Phone:503-626-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR01-R-17101Y00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR01-R-17OtherMHACBO CADC-II
OR500786243Medicaid