Provider Demographics
NPI:1780176339
Name:MCCUTCHEON, KAYLA (QMHA)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:MCCUTCHEON
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:
Other - Last Name:ARCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1234
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-8234
Mailing Address - Country:US
Mailing Address - Phone:503-782-4499
Mailing Address - Fax:
Practice Address - Street 1:58646 MCNULTY WAY
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-6210
Practice Address - Country:US
Practice Address - Phone:503-782-4499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1720105489Medicaid