Provider Demographics
NPI:1760850549
Name:RAZAVI, MICHAEL DAVID (MPH, CADC I, PRC,)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:RAZAVI
Suffix:
Gender:M
Credentials:MPH, CADC I, PRC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2054 N VANCOUVER AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1917
Mailing Address - Country:US
Mailing Address - Phone:503-231-8164
Mailing Address - Fax:
Practice Address - Street 1:2054 N VANCOUVER AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1917
Practice Address - Country:US
Practice Address - Phone:503-231-8164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11-09-48101YA0400X
OR15-PRC-004175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)