Provider Demographics
NPI:1467654582
Name:KIRK, ANTHONY DAVID (QMHA)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:DAVID
Last Name:KIRK
Suffix:
Gender:M
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 JASMINE CIR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97351-9578
Mailing Address - Country:US
Mailing Address - Phone:503-838-4866
Mailing Address - Fax:
Practice Address - Street 1:2435 GREENWAY DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4535
Practice Address - Country:US
Practice Address - Phone:503-991-6619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator