Provider Demographics
NPI:1821691668
Name:MCDONALD, TILDEN JR (CRM/PSS)
Entity type:Individual
Prefix:
First Name:TILDEN
Middle Name:
Last Name:MCDONALD
Suffix:JR
Gender:M
Credentials:CRM/PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:503-621-2235
Practice Address - Street 1:355 NW DIVISION ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5523
Practice Address - Country:US
Practice Address - Phone:971-225-6695
Practice Address - Fax:503-231-1654
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000004376175T00000X
OR20-CRM-067101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500787753Medicaid