Basic Information
| Provider Information | |||||||||
| NPI: | 1235798372 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HADDEN | ||||||||
| FirstName: | TIMOTHY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14600 NW CORNELL RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972295442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036453581 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 NE 7TH ST | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970305604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036615455 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2019 | ||||||||
| LastUpdateDate: | 12/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/12/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.