Healthcare Provider Details

I. General information

NPI: 1235506171
Provider Name (Legal Business Name): JOYCE BAILEY QMHA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2015
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 NE DIVISION ST
GRESHAM OR
97030-4617
US

IV. Provider business mailing address

3443 NE 15TH ST
GRESHAM OR
97030-4503
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-6575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number174378371
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: