Provider Demographics
NPI:1063221760
Name:BRUDERER, DEREK VAUGHN (CADC-R)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:VAUGHN
Last Name:BRUDERER
Suffix:
Gender:M
Credentials:CADC-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13700 SE CENTER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-3524
Mailing Address - Country:US
Mailing Address - Phone:971-379-0207
Mailing Address - Fax:
Practice Address - Street 1:1122 NE 122ND AVE STE A200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2083
Practice Address - Country:US
Practice Address - Phone:503-954-1890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-24-4784101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)