Healthcare Provider Details

I. General information

NPI: 1386094928
Provider Name (Legal Business Name): WENDIE S MOYNIHAN QMHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WENDIE S GREEN QMHA

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 W B ST BLDG B2
SPRINGFIELD OR
97477-4575
US

IV. Provider business mailing address

PO BOX 852
SPRINGFIELD OR
97477-0142
US

V. Phone/Fax

Practice location:
  • Phone: 541-423-2633
  • Fax:
Mailing address:
  • Phone: 541-423-2633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: