Healthcare Provider Details

I. General information

NPI: 1164342382
Provider Name (Legal Business Name): MIA DAY QUALKINBUSH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 S HOLLY ST
MEDFORD OR
97501-3113
US

IV. Provider business mailing address

140 S HOLLY ST
MEDFORD OR
97501-3113
US

V. Phone/Fax

Practice location:
  • Phone: 541-770-7726
  • Fax: 541-774-7964
Mailing address:
  • Phone: 541-770-7726
  • Fax: 541-774-7964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number26-QMHA-R-8507
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: