Provider Demographics
NPI:1386477099
Name:JOHNSON-BANIK, ZECHARIAH (PSS, QMHA-R)
Entity type:Individual
Prefix:
First Name:ZECHARIAH
Middle Name:
Last Name:JOHNSON-BANIK
Suffix:
Gender:M
Credentials:PSS, QMHA-R
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:ZACHARY
Other - Last Name:YELNOSKY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSS
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:
Practice Address - Street 1:12360 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1042
Practice Address - Country:US
Practice Address - Phone:971-279-4800
Practice Address - Fax:971-279-2051
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24-QMHA-R-6024101YM0800X
OR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health