Provider Demographics
NPI:1801242730
Name:BLACK, TANYA L (CRM/PSS)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:L
Last Name:BLACK
Suffix:
Gender:F
Credentials:CRM/PSS
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:L
Other - Last Name:BLACKHORSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRM/PSS
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 1:1438 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1140
Practice Address - Country:US
Practice Address - Phone:971-261-0544
Practice Address - Fax:971-245-3043
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2025-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000001319175T00000X
OR16-CRM-033101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500730810Medicaid
OR500819326Medicaid