Healthcare Provider Details

I. General information

NPI: 1649091471
Provider Name (Legal Business Name): RENEE C PECK QMHA-R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 NE MAPLE AVE
REDMOND OR
97756-8527
US

IV. Provider business mailing address

PO BOX 1710
REDMOND OR
97756-0516
US

V. Phone/Fax

Practice location:
  • Phone: 541-504-9577
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: