Healthcare Provider Details

I. General information

NPI: 1508899550
Provider Name (Legal Business Name): RENEE ERICA BOAK QMHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2908 NE KILLINGSWORTH ST
PORTLAND OR
97211-6812
US

IV. Provider business mailing address

1706 SE REEDWAY ST
PORTLAND OR
97202-5127
US

V. Phone/Fax

Practice location:
  • Phone: 503-287-8009
  • Fax: 503-287-7684
Mailing address:
  • Phone: 518-225-2564
  • Fax: 503-287-7684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: