Provider Demographics
NPI:1497243109
Name:TAYLOR, LARRY (CRM/PSS/QMHA-I)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:CRM/PSS/QMHA-I
Other - Prefix:
Other - First Name:LAWRENCE
Other - Middle Name:
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRM/PSS/QMHA-I
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:1438 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1140
Practice Address - Country:US
Practice Address - Phone:503-548-0346
Practice Address - Fax:503-232-5959
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19-QMHA-I-00478101YM0800X
ORTHW000002408175T00000X
OR15-CRM-017101YA0400X
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500760853Medicaid
OR500743133Medicaid