Provider Demographics
NPI:1720769276
Name:MACIAS, MARISA (QMHA-R)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:MACIAS
Suffix:
Gender:F
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 1:211 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:971-260-0355
Practice Address - Street 1:211 SE CARUTHERS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4502
Practice Address - Country:US
Practice Address - Phone:503-224-1044
Practice Address - Fax:971-260-0355
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHA-R-3893101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500823661Medicaid
OR500823661Medicaid