Provider Demographics
NPI:1528566445
Name:REICHARDT, MATHEW
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:
Last Name:REICHARDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 NW 6TH AVENUE
Mailing Address - Street 2:ATTN: BBIS CREDENTIALING
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209
Mailing Address - Country:US
Mailing Address - Phone:503-294-1681
Mailing Address - Fax:503-241-7419
Practice Address - Street 1:727 W BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3514
Practice Address - Country:US
Practice Address - Phone:503-228-4533
Practice Address - Fax:503-228-4618
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)