Provider Demographics
NPI:1215398375
Name:BACCOUCHE, HANNAH C (LBA, QMHP, RCFA)
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:C
Last Name:BACCOUCHE
Suffix:
Gender:F
Credentials:LBA, QMHP, RCFA
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:C
Other - Last Name:BYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3587 HEATHROW WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4004
Mailing Address - Country:US
Mailing Address - Phone:541-858-8170
Mailing Address - Fax:
Practice Address - Street 1:17720 NE HALSEY ST STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-6771
Practice Address - Country:US
Practice Address - Phone:503-654-7654
Practice Address - Fax:503-654-7333
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PROFESSIONALLICENSE101YM0800X
1-18-32599103K00000X
OR10197559103K00000X
OR21-QMHP-R-0684101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500707966Medicaid