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NPI Code Detail

MEDICARE: MARY KATHLEEN COOK QMHA-R, CRM

MEDICARE: MARY KATHLEEN COOK QMHA-R, CRM
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YA0400XAddiction (Substance Use Disorder) Counselor25-CRM-4813OR
2101YM0800XMental Health Counselor22-QMHA-R-2749OR

General Provider Information

NPI Number : 1114538840
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARY KATHLEEN COOK QMHA-R, CRM
Provider Business Mailing Address
First Line : 8915 SW CENTER ST
Second Line :
City : TIGARD
State : OR
Zip : 97223-6307
Country : US
Telephone Number : 503-726-3690
Fax Number :
Provider Business Practice Location Address
First Line : 8915 SW CENTER ST
Second Line :
City : TIGARD
State : OR
Zip : 97223-6307
Country : US
Telephone Number : 503-726-3690
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/15/2020
Last Update Date : 03/02/2026

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