Healthcare Provider Details

I. General information

NPI: 1225969843
Provider Name (Legal Business Name): LEWIS EDWARD BIRDSEYE IV QMHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 MARTIN LUTHER KING JR BLVD
EUGENE OR
97401-5824
US

IV. Provider business mailing address

2411 MARTIN LUTHER KING JR BLVD
EUGENE OR
97401-5824
US

V. Phone/Fax

Practice location:
  • Phone: 541-682-4035
  • Fax:
Mailing address:
  • Phone: 541-682-4035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number24-QMHA-I-004149
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: