Healthcare Provider Details

I. General information

NPI: 1053035378
Provider Name (Legal Business Name): KATELYN RUSSELL-ATCHLEY QMHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 SW ACADEMY ST
DALLAS OR
97338-1922
US

IV. Provider business mailing address

350 SE HAWTHORNE AVE
DALLAS OR
97338-1718
US

V. Phone/Fax

Practice location:
  • Phone: 503-623-9289
  • Fax:
Mailing address:
  • Phone: 713-269-2630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: