Provider Demographics
NPI:1588056964
Name:BLOMBERG, PHILLIP SPENCER (CADC-I)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:SPENCER
Last Name:BLOMBERG
Suffix:
Gender:M
Credentials:CADC-I
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
Mailing Address - Country:US
Mailing Address - Phone:503-239-8400
Mailing Address - Fax:503-269-8407
Practice Address - Street 1:18088 SE MARKET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233
Practice Address - Country:US
Practice Address - Phone:503-760-1003
Practice Address - Fax:503-492-7379
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14-09-01101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)