Basic Information
| Provider Information | |||||||||
| NPI: | 1013059617 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUAYLE | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 272 NW MEDICAL LOOP STE E | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974715545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419004285 | ||||||||
| FaxNumber: | 8888102993 | ||||||||
| Practice Location | |||||||||
| Address1: | 755 E 2ND AVE | ||||||||
| Address2: | SUITE 2D | ||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813015498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705707309 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 1017 | CO | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | T1562 | OR | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | T1562 | 01 | OR | STATE LICENSES MARRIAGE AND FAMILY THERAPIST | OTHER |