Provider Demographics
NPI:1225652001
Name:TALAWYMA, JOHNNY L JR (BBH-LAC-LIC-64263)
Entity type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:L
Last Name:TALAWYMA
Suffix:JR
Gender:M
Credentials:BBH-LAC-LIC-64263
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 SE CARUTHERS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4502
Mailing Address - Country:US
Mailing Address - Phone:971-217-9008
Mailing Address - Fax:971-260-0355
Practice Address - Street 1:17645 NW SAINT HELENS RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97231-1729
Practice Address - Country:US
Practice Address - Phone:503-621-1069
Practice Address - Fax:503-621-0200
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2025-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24-QMHP-R-3301101YM0800X
MTBBH-LAC-LIC-64263101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health