MEDICARE: MRS. THERESA MARIE RICHTERS QMHP,LCSW

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	101YM0800X	Mental Health Counselor
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1497769830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. THERESA MARIE RICHTERS QMHP,LCSW

Provider Business Mailing Address
First Line	:	1723 ELM ST
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-2519
Country	:	US
Telephone Number	:	503-890-2729
Fax Number	:	503-747-3951

Provider Business Practice Location Address
First Line	:	1723 ELM ST
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-2519
Country	:	US
Telephone Number	:	503-890-2729
Fax Number	:	503-747-3951

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

Provider Enumeration Date	:	07/29/2006
Last Update Date	:	02/15/2013

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