Provider Demographics
NPI:1366985707
Name:FLYNN, GERALD TODD (CADC II)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:TODD
Last Name:FLYNN
Suffix:
Gender:M
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 NW 160TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-7614
Mailing Address - Country:US
Mailing Address - Phone:503-332-4969
Mailing Address - Fax:
Practice Address - Street 1:1316 SE 12TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3604
Practice Address - Country:US
Practice Address - Phone:503-897-1916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-01
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12-12-75101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health