1285233460 NPI number — MADELYNN R TICE QMHA-I

Table of content: (NPI 1588070874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285233460 NPI number — MADELYNN R TICE QMHA-I

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TICE
Provider First Name:
MADELYNN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
QMHA-I
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:
1285233460
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2021
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:
10/20/2020

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:  20-QMHA-R-0816 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 21-QMHA-I-003183 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 500785589 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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