MEDICARE: MAUREEN ANITA DE LEON QMHPR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1427717230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAUREEN ANITA DE LEON QMHPR

Provider Business Mailing Address
First Line	:	1609 N 10TH ST
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-2644
Country	:	US
Telephone Number	:	541-808-3597
Fax Number	:

Provider Business Practice Location Address
First Line	:	833 ANDERSON AVE STE 6
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-4641
Country	:	US
Telephone Number	:	541-286-6238
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2021
Last Update Date	:	12/09/2021

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