Provider Demographics
NPI:1598518573
Name:LONGWELL, MORIAH (QMHA-R)
Entity Type:Individual
Prefix:
First Name:MORIAH
Middle Name:
Last Name:LONGWELL
Suffix:
Gender:F
Credentials:QMHA-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 FELINA AVE NE APT 212
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-1376
Mailing Address - Country:US
Mailing Address - Phone:509-420-0041
Mailing Address - Fax:
Practice Address - Street 1:4080 REED RD SE STE 150
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1335
Practice Address - Country:US
Practice Address - Phone:503-581-1732
Practice Address - Fax:503-363-4607
Is Sole Proprietor?:No
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24-QMHA-R-5041171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator