Provider Demographics
NPI:1538619069
Name:WEERATUNGE, DYLAN (CADC CANDIDATE/QMHA)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:WEERATUNGE
Suffix:
Gender:M
Credentials:CADC CANDIDATE/QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8459
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-8459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:847 NE 19TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232
Practice Address - Country:US
Practice Address - Phone:503-238-0769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-07
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-17-256101YA0400X
OR101YM0800X
372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500724989Medicaid