MEDICARE: MS. KATHY QUERIN M.A.

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
1	101Y00000X	Counselor	C2016	OR
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	09-06-41	OR

General Provider Information

NPI Number	:	1528359262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATHY QUERIN M.A.

Provider Business Mailing Address
First Line	:	7175 SW BEVELAND RD
Second Line	:	SUITE 105
City	:	PORTLAND
State	:	OR
Zip	:	97223-8665
Country	:	US
Telephone Number	:	503-620-4000
Fax Number	:	503-639-8987

Provider Business Practice Location Address
First Line	:	7175 SW BEVELAND RD
Second Line	:	SUITE 105
City	:	PORTLAND
State	:	OR
Zip	:	97223-8665
Country	:	US
Telephone Number	:	503-620-4000
Fax Number	:	503-639-8987

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2011
Last Update Date	:	04/28/2011

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