Healthcare Provider Details

I. General information

NPI: 1104599836
Provider Name (Legal Business Name): MIKAYLA QUACKENBUSH QMHA, COUNSELOR II
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 NE 8TH ST APT 302
GRESHAM OR
97030-5762
US

IV. Provider business mailing address

1201 NE 8TH ST APT 302
GRESHAM OR
97030-5762
US

V. Phone/Fax

Practice location:
  • Phone: 503-320-5182
  • Fax:
Mailing address:
  • Phone: 503-320-5182
  • 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: