MEDICARE: SHIRLEY DAINE HOWELL QMHA

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	172V00000X	Community Health Worker		OR
2	175T00000X	Peer Specialist		OR
3	224Z00000X	Occupational Therapy Assistant	1028905	OR
4	171M00000X	Case Manager/Care Coordinator		OR

General Provider Information

NPI Number	:	1629141080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIRLEY DAINE HOWELL QMHA

Provider Business Mailing Address
First Line	:	1345 BIRCH AVE
Second Line	:	P.O. BOX 5
City	:	COTTAGE GROVE
State	:	OR
Zip	:	97424-1416
Country	:	US
Telephone Number	:	541-942-3939
Fax Number	:	541-942-9310

Provider Business Practice Location Address
First Line	:	1345 BIRCH AVE
Second Line	:
City	:	COTTAGE GROVE
State	:	OR
Zip	:	97424-1416
Country	:	US
Telephone Number	:	541-942-3939
Fax Number	:	541-942-9310

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

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	02/19/2016

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