Basic Information
| Provider Information | |||||||||
| NPI: | 1831537422 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MYERS | ||||||||
| FirstName: | CALVIN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CADC II/LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5933 N HAIGHT AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972172180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105950325 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10564 SE WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972162809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032289229 | ||||||||
| FaxNumber: | 5032289558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2013 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 14-02-01 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | 17-06-18 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 14564 | CA | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | L5541 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 500677671 | 05 | OR | MEDICAID | 500680652 | 05 | OR | MEDICAID |