1437977998 NPI number — ELIZABETH JOHANNA DECLEENE QMHA

Table of content: ELIZABETH JOHANNA DECLEENE QMHA (NPI 1437977998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437977998 NPI number — ELIZABETH JOHANNA DECLEENE QMHA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DECLEENE
Provider First Name:
ELIZABETH
Provider Middle Name:
JOHANNA
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:
1437977998
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 469
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HEPPNER
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97836-0469
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-676-9161
Provider Business Mailing Address Fax Number:
541-676-5662

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
299 N COLUMBIA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILTON FREEWATER
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97862-1368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-276-6207
Provider Business Practice Location Address Fax Number:
541-938-4180
Provider Enumeration Date:
10/02/2024

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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