Basic Information
| Provider Information | |||||||||
| NPI: | 1194106229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLDRITT | ||||||||
| FirstName: | RANDI | ||||||||
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| Credential: | CRM, CADC I | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 E BURNSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712258127 | ||||||||
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| Practice Location | |||||||||
| Address1: | 112 BEAVERCREEK RD | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032385203 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2015 | ||||||||
| LastUpdateDate: | 10/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 175T00000X | 15-CRM-061 | OR | Y |
ID Information
| ID | Type | State | Issuer | Description | 1194106229 | 05 | OR | MEDICAID |