Provider Demographics
NPI:1508591637
Name:PEARSON, THEODORE LEE III (CADC I)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:LEE
Last Name:PEARSON
Suffix:III
Gender:M
Credentials:CADC I
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 1038
Mailing Address - Street 2:
Mailing Address - City:WEST TISBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02575-1038
Mailing Address - Country:US
Mailing Address - Phone:503-475-6246
Mailing Address - Fax:
Practice Address - Street 1:1122 NE 122ND AVE # 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2081
Practice Address - Country:US
Practice Address - Phone:503-732-6653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20-05-10416101YA0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR20-05-10416OtherMHACBO