Provider Demographics
NPI:1538517420
Name:CAMPBELL, SADIE A (PSS/QMHA-I)
Entity Type:Individual
Prefix:
First Name:SADIE
Middle Name:A
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PSS/QMHA-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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 1:620 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:971-274-3757
Practice Address - Fax:503-912-5740
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19-QMHA-I-00637101YM0800X
ORTHW000001573175T00000X
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500747179Medicaid
OR500733945Medicaid