Provider Demographics
NPI:1609584168
Name:BUCHANAN, MYLES
Entity Type:Individual
Prefix:
First Name:MYLES
Middle Name:
Last Name:BUCHANAN
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 1:3055 NW YEON AVE # 64
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-1519
Mailing Address - Country:US
Mailing Address - Phone:541-995-0868
Mailing Address - Fax:503-676-5985
Practice Address - Street 1:6725 SE 74TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-7237
Practice Address - Country:US
Practice Address - Phone:541-995-0868
Practice Address - Fax:503-676-5985
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR7750101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health