Provider Demographics
NPI:1669161014
Name:TUCKWIN, SAMUEL ALLEN (CADC-R/CSWA/QMHP-R)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ALLEN
Last Name:TUCKWIN
Suffix:
Gender:
Credentials:CADC-R/CSWA/QMHP-R
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:ALLEN
Other - Last Name:TUCKWIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CADC-R/CSWA/QMHP-R
Mailing Address - Street 1:211 SE CARUTHERS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4502
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:971-260-0355
Practice Address - Street 1:620 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7514
Practice Address - Country:US
Practice Address - Phone:971-274-3757
Practice Address - Fax:503-912-5740
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-24-3972101YA0400X
OR23-QMHP-R-2293101YM0800X
WASC61570839104100000X
ORA14705104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500819391Medicaid