Healthcare Provider Details

I. General information

NPI: 1225656366
Provider Name (Legal Business Name): REGINA THERESA BURCK QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2020
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21440 SE STARK ST
GRESHAM OR
97030-2024
US

IV. Provider business mailing address

11010 SE DIVISION ST STE 200
PORTLAND OR
97266-6400
US

V. Phone/Fax

Practice location:
  • Phone: 971-703-4623
  • Fax:
Mailing address:
  • Phone: 971-703-4623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number24-QMHPC-001573
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: