Provider Demographics
NPI:1245769504
Name:MCSPADDEN, RAEANN N (BS QMHA)
Entity Type:Individual
Prefix:
First Name:RAEANN
Middle Name:N
Last Name:MCSPADDEN
Suffix:
Gender:F
Credentials:BS QMHA
Other - Prefix:
Other - First Name:RAEANN
Other - Middle Name:N
Other - Last Name:BARNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1650 SW 45TH PL
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-1768
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 SW 45TH PL
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333
Practice Address - Country:US
Practice Address - Phone:541-757-8068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR106S00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR128715Medicaid