Provider Demographics
NPI:1790337749
Name:CLEETON, CHEYENNE A (CADC I/QMHA-R)
Entity Type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:A
Last Name:CLEETON
Suffix:
Gender:F
Credentials:CADC I/QMHA-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 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:2019-07-10
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22-QMHA-R-2712101YM0800X
OR20-07-01101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500769842Medicaid
OR500809541Medicaid