Healthcare Provider Details

I. General information

NPI: 1841720752
Provider Name (Legal Business Name): SHELBY WILSON QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 NE HANCOCK ST
PORTLAND OR
97212-3955
US

IV. Provider business mailing address

211 SE CARUTHERS ST
PORTLAND OR
97214-4502
US

V. Phone/Fax

Practice location:
  • Phone: 503-230-9875
  • Fax: 503-331-3441
Mailing address:
  • Phone: 971-217-9008
  • Fax: 971-260-0355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number26-QMHP-R-4543
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: