Provider Demographics
NPI:1083376156
Name:TRAVIS, REBEKAH L (QMHA)
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:L
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:REYAH
Other - Middle Name:L
Other - Last Name:TRAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:QMHA
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:12360 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1042
Practice Address - Country:US
Practice Address - Phone:971-279-4800
Practice Address - Fax:971-279-2051
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
OR22-QMHA-R-2352101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500800531Medicaid