Provider Demographics
NPI:1215791876
Name:DIAZ, BRYAN RICHARD (CADC-R)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:RICHARD
Last Name:DIAZ
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 1:411 NE 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-4801
Mailing Address - Country:US
Mailing Address - Phone:971-386-2126
Mailing Address - Fax:
Practice Address - Street 1:411 NE 19TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-4801
Practice Address - Country:US
Practice Address - Phone:971-386-2126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-24-3679101YA0400X
OR23-CRM-2748175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)