Healthcare Provider Details

I. General information

NPI: 1982173589
Provider Name (Legal Business Name): PRENTICE GEARY CADC III, QMHA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 02/13/2026
Certification Date: 02/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 82ND DR
GLADSTONE OR
97027-1803
US

IV. Provider business mailing address

880 82ND DR
GLADSTONE OR
97027-1803
US

V. Phone/Fax

Practice location:
  • Phone: 971-378-0367
  • Fax: 503-974-9679
Mailing address:
  • Phone: 971-378-0367
  • Fax: 503-974-9679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18-01-43
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number21-QMHA-II-000009
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: