Healthcare Provider Details

I. General information

NPI: 1669242129
Provider Name (Legal Business Name): CRYSTAL MACIAS QMHA-R, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CRYSTAL EHRICH QMHA-R, CADC-R, PHN

II. Dates (important events)

Enumeration Date: 01/05/2024
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63158 DESCHUTES MARKET RD 337
BEND OR
97701-2973
US

IV. Provider business mailing address

63158 DESCHUTES MARKET RD 337
BEND OR
97701-2973
US

V. Phone/Fax

Practice location:
  • Phone: 458-600-8552
  • Fax:
Mailing address:
  • Phone: 458-600-8552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-24-3590
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number23-QMHA-R-3759
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: