Provider Demographics
NPI:1770274482
Name:RADFORD, DERRICK (MA)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:RADFORD
Suffix:
Gender:
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5441 S MACADAM AVE STE A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-6106
Mailing Address - Country:US
Mailing Address - Phone:971-290-4398
Mailing Address - Fax:
Practice Address - Street 1:5441 S MACADAM AVE STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-6106
Practice Address - Country:US
Practice Address - Phone:971-290-4398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61660503101YM0800X
ORR9219101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health