1073293221 NPI number — JUDITH YADIRA BRACAMONTES QMHA-R

Table of content: JUDITH YADIRA BRACAMONTES QMHA-R (NPI 1073293221)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073293221 NPI number — JUDITH YADIRA BRACAMONTES QMHA-R

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
BRACAMONTES

Provider First Name:
JUDITH

Provider Middle Name:
YADIRA

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:
QMHA-R

Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:
BRACAMONTES

Provider Other First Name:
JUDY

Provider Other Middle Name:
YADIRA

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:
QMHA-R

Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1073293221

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
08/30/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1776 SW MADISON ST

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
PORTLAND

Provider Business Mailing Address State Name:
OR

Provider Business Mailing Address Postal Code:
97205-1715

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
503-224-1044

Provider Business Mailing Address Fax Number:
503-621-2235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620 NE 2ND ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
GRESHAM

Provider Business Practice Location Address State Name:
OR

Provider Business Practice Location Address Postal Code:
97030-7514

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
971-274-3757

Provider Business Practice Location Address Fax Number:
503-912-5740

Provider Enumeration Date:
07/21/2023

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: 101YM0800X , with the licence number: 23-QMHA-R-4302 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .