Basic Information
| Provider Information | |||||||||
| NPI: | 1851663389 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EASLICK | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | ROBERT | ||||||||
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| OtherLastName: | EASLICK | ||||||||
| OtherFirstName: | BRYAN | ||||||||
| OtherMiddleName: | ROBERT | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CADC 1 | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 16756 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972920756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9713863407 | ||||||||
| FaxNumber: | 5032082596 | ||||||||
| Practice Location | |||||||||
| Address1: | 704 MAIN ST STE 302 | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970451842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9713863407 | ||||||||
| FaxNumber: | 5037236653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2012 | ||||||||
| LastUpdateDate: | 06/26/2017 | ||||||||
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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 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 175T00000X | 15-CRM-049 | OR | Y |
No ID Information.