Healthcare Provider Details

I. General information

NPI: 1013387042
Provider Name (Legal Business Name): EMILY CULBERTSON CADC II, QMHA II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2015
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 NW 5TH ST BOX 1710
REDMOND OR
97756-1869
US

IV. Provider business mailing address

340 NW 5TH ST BOX 1710
REDMOND OR
97756-1869
US

V. Phone/Fax

Practice location:
  • Phone: 540-516-4087
  • Fax: 541-504-1195
Mailing address:
  • Phone: 541-516-4099
  • Fax: 541-504-1195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number23-QMHA-II-000113
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number14-CRM-076
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number23-08-20311
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: