Provider Demographics
NPI:1053992990
Name:MARK, EMMA R (QMHA-I)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:R
Last Name:MARK
Suffix:
Gender:
Credentials:QMHA-I
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:503-621-2235
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:2021-04-20
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24-QMHA-I-004246101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500791871Medicaid