Provider Demographics
NPI:1851663389
Name:EASLICK, BRYAN ROBERT
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:ROBERT
Last Name:EASLICK
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:BRYAN
Other - Middle Name:ROBERT
Other - Last Name:EASLICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CADC 1
Mailing Address - Street 1:PO BOX 16756
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0756
Mailing Address - Country:US
Mailing Address - Phone:971-386-3407
Mailing Address - Fax:503-208-2596
Practice Address - Street 1:704 MAIN ST STE 302
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1842
Practice Address - Country:US
Practice Address - Phone:971-386-3407
Practice Address - Fax:503-723-6653
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
OR15-CRM-049175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)