Provider Demographics
NPI:1821580515
Name:TAYLOR, SAMANTHA K (CADC I/QMHA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:K
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:CADC I/QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13030 SE RUSK RD APT 12
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2184
Mailing Address - Country:US
Mailing Address - Phone:971-295-7751
Mailing Address - Fax:
Practice Address - Street 1:620 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:971-274-3757
Practice Address - Fax:503-912-5740
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-18-122101YA0400X
OR101YM0800X
OR18-04-27101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500744091Medicaid
OR500746027Medicaid