Provider Demographics
NPI:1659828184
Name:TYNAN, CHERI I
Entity Type:Individual
Prefix:
First Name:CHERI
Middle Name:
Last Name:TYNAN
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7934 SE KNIGHT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-5859
Mailing Address - Country:US
Mailing Address - Phone:971-832-0672
Mailing Address - Fax:
Practice Address - Street 1:7934 S/E KNIGHT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-5859
Practice Address - Country:US
Practice Address - Phone:971-832-0672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175T00000X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR175T00000XOtherPEER SUPPORT SPECALIST