Provider Demographics
NPI:1629825906
Name:PETCHELL, TRAVIS SCOTT (PWS/QMHA-R)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:SCOTT
Last Name:PETCHELL
Suffix:
Gender:M
Credentials:PWS/QMHA-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 SE CARUTHERS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4502
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:971-260-0355
Practice Address - Street 1:211 SE CARUTHERS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4502
Practice Address - Country:US
Practice Address - Phone:503-224-1044
Practice Address - Fax:971-260-0355
Is Sole Proprietor?:No
Enumeration Date:2024-05-03
Last Update Date:2025-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000108531175T00000X
OR25-QMHA-R-7767101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500843961Medicaid