Provider Demographics
NPI:1780130690
Name:GARNER, CHARLOTTE MARY (CADC III/CSWA/QMHP-R)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:MARY
Last Name:GARNER
Suffix:
Gender:F
Credentials:CADC III/CSWA/QMHP-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:17645 NW SAINT HELENS RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97231-1729
Practice Address - Country:US
Practice Address - Phone:503-621-1069
Practice Address - Fax:503-621-0200
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19-09-30101YA0400X
OR23-QMHP-R-2079101YM0800X
ORA14367104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500804873Medicaid
OR500718742Medicaid