Basic Information
| Provider Information | |||||||||
| NPI: | 1023528254 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOLER | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | CADC CANDIDATE/QMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 847 NE 19TH AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032380769 | ||||||||
| FaxNumber: | 5037649042 | ||||||||
| Practice Location | |||||||||
| Address1: | 9111 NE SUNDERLAND AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972111708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032806646 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | OR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YA0400X | T-17-257 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.