Provider Demographics
NPI:1336444967
Name:DORN-MEDEIROS, CORT MICAH (MS, CADC I)
Entity Type:Individual
Prefix:
First Name:CORT
Middle Name:MICAH
Last Name:DORN-MEDEIROS
Suffix:
Gender:F
Credentials:MS, CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10564 SE WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2809
Mailing Address - Country:US
Mailing Address - Phone:503-988-5400
Mailing Address - Fax:503-988-5668
Practice Address - Street 1:2020 SE 182ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-5692
Practice Address - Country:US
Practice Address - Phone:503-988-5400
Practice Address - Fax:503-988-5668
Is Sole Proprietor?:No
Enumeration Date:2011-01-12
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
ORC3390101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional