=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972096139
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT QUAMME BS, CADC I
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2018
-----------------------------------------------------
Last Update Date | 11/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 337 SE FOWLER ST
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97470-4348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-464-6535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1288
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97470-0368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-464-6536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | T-17-340
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 1366697690
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------