Provider Demographics
NPI:1417528621
Name:POWELL, STEPHANIE JOY (QMHA-R)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JOY
Last Name:POWELL
Suffix:
Gender:F
Credentials:QMHA-R
Other - Prefix:
Other - First Name:STEPH
Other - Middle Name:JOY
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:QMHA-R
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:2021-07-08
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHA-R-4248101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500824245Medicaid