Provider Demographics
NPI:1376705103
Name:CLELAND, KATHRYN (QMHA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:CLELAND
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-1307
Mailing Address - Country:US
Mailing Address - Phone:541-942-2850
Mailing Address - Fax:541-942-1574
Practice Address - Street 1:410 N 9TH ST
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-1307
Practice Address - Country:US
Practice Address - Phone:541-942-2850
Practice Address - Fax:541-942-1574
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR019047Medicaid