Provider Demographics
NPI:1568294361
Name:HERSI, LIBAN (QMHA-R)
Entity type:Individual
Prefix:
First Name:LIBAN
Middle Name:
Last Name:HERSI
Suffix:
Gender:M
Credentials:QMHA-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10011 SE DIVISION ST STE 203
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-1354
Mailing Address - Country:US
Mailing Address - Phone:503-964-5182
Mailing Address - Fax:503-964-5261
Practice Address - Street 1:10011 SE DIVISION ST STE 203
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-1354
Practice Address - Country:US
Practice Address - Phone:503-964-5182
Practice Address - Fax:503-964-5261
Is Sole Proprietor?:No
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24-QMHA-R-4840101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health