Provider Demographics
NPI:1558482190
Name:VANDEHEY, TARA R (CADC II/QMHP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:R
Last Name:VANDEHEY
Suffix:
Gender:F
Credentials:CADC II/QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1328
Mailing Address - Country:US
Mailing Address - Phone:503-239-8400
Mailing Address - Fax:503-239-8407
Practice Address - Street 1:1030 NE COUCH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3067
Practice Address - Country:US
Practice Address - Phone:503-239-8400
Practice Address - Fax:503-239-8407
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR98-04-77101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500640364Medicaid
OR500725404Medicaid