1710672449 NPI number — MR. SHANE SMEDLEY QMHA-R, CRM, PSS-AD

Table of content: MR. SHANE SMEDLEY QMHA-R, CRM, PSS-AD (NPI 1710672449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710672449 NPI number — MR. SHANE SMEDLEY QMHA-R, CRM, PSS-AD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMEDLEY
Provider First Name:
SHANE
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
QMHA-R, CRM, PSS-AD
Provider Gender Code:
M

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:
1710672449
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
361 YEWWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHADY COVE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97539-9794
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
458-204-8226
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
361 YEWWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHADY COVE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97539-9794
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
458-204-8226
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/10/2023

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: 175T00000X , with the licence number:  108144 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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