Provider Demographics
NPI:1588221691
Name:SUCHANEK, GLEN ALLEN I (CADCI, CRM)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:ALLEN
Last Name:SUCHANEK
Suffix:I
Gender:M
Credentials:CADCI, CRM
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 AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3609
Mailing Address - Country:US
Mailing Address - Phone:971-269-6812
Mailing Address - Fax:503-208-3186
Practice Address - Street 1:3811 SE CONCORD RD
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:OR
Practice Address - Zip Code:97267-3911
Practice Address - Country:US
Practice Address - Phone:971-269-6812
Practice Address - Fax:503-208-3186
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18-07-04101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)