Provider Demographics
NPI:1760649511
Name:BUTTI, BAHER S R (QMHP-C)
Entity Type:Individual
Prefix:
First Name:BAHER
Middle Name:S R
Last Name:BUTTI
Suffix:
Gender:M
Credentials:QMHP-C
Other - Prefix:
Other - First Name:BAHER
Other - Middle Name:SAMI RAPHAEL
Other - Last Name:BUTTI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:QMHP-C
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 1:1438 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1140
Practice Address - Country:US
Practice Address - Phone:503-548-0346
Practice Address - Fax:503-232-5959
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19-QMHPC-00383101YM0800X, 101YM0800X
372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500728499Medicaid