Provider Demographics
NPI:1902299712
Name:CLOOTEN, ROGER DALE
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:DALE
Last Name:CLOOTEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 N 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-3003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:254 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-3003
Practice Address - Country:US
Practice Address - Phone:503-847-0124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12CRM031101YA0400X
OR81-0634495101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR81-0634495Medicaid
OR81-0634495Medicare PIN