Provider Demographics
NPI:1124685128
Name:QUICK, CARLY R (QMHA)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:R
Last Name:QUICK
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 CENTENNIAL PLZ
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2474
Mailing Address - Country:US
Mailing Address - Phone:541-912-4085
Mailing Address - Fax:
Practice Address - Street 1:2145 CENTENNIAL PLZ
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2474
Practice Address - Country:US
Practice Address - Phone:541-912-4085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-24
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
OH251S00000X
OHS.2001529-TRNE390200000X
OR21-QMHA-R-1030171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0350549Medicaid
OR1639231715Medicaid