1124515184 NPI number — SHELLEY M DICKASON QMHA

Table of content: SHELLEY M DICKASON QMHA (NPI 1124515184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124515184 NPI number — SHELLEY M DICKASON QMHA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKASON
Provider First Name:
SHELLEY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
QMHA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124515184
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2577 NE COURTNEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97701-7752
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-322-7500
Provider Business Mailing Address Fax Number:
541-322-7565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51340 HIGHWAY 97
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA PINE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97739-9871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-322-7500
Provider Business Practice Location Address Fax Number:
541-322-7565
Provider Enumeration Date:
04/16/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  19-QMHA-I-00890 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)