Provider Demographics
NPI:1104050947
Name:PENA-BALTAZAR, LUPITA (QMHA)
Entity type:Individual
Prefix:MISS
First Name:LUPITA
Middle Name:
Last Name:PENA-BALTAZAR
Suffix:
Gender:
Credentials:QMHA
Other - Prefix:
Other - First Name:LUPITA
Other - Middle Name:
Other - Last Name:PENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:7515 FALCON CREST DR # 200
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-5014
Mailing Address - Country:US
Mailing Address - Phone:541-904-5216
Mailing Address - Fax:541-527-4347
Practice Address - Street 1:1310 MERIDIAN DR
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-9668
Practice Address - Country:US
Practice Address - Phone:503-953-0310
Practice Address - Fax:503-386-0439
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
ORL107331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
L10733OtherOREGON BOARD OF LICENSED SOCIAL WORKERS