Basic Information
| Provider Information | |||||||||
| NPI: | 1790219962 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUGHES | ||||||||
| FirstName: | CLINTON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | QMHA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherMiddleName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3876 BEVERLY AVE NE | ||||||||
| Address2: | BLDG G | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973051319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033612724 | ||||||||
| FaxNumber: | 5033612782 | ||||||||
| Practice Location | |||||||||
| Address1: | 3876 BEVERLY AVE NE | ||||||||
| Address2: | BLDG G | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973051319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033612724 | ||||||||
| FaxNumber: | 5033612782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2017 | ||||||||
| LastUpdateDate: | 05/05/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.