Provider Demographics
NPI:1003799636
Name:HOLLISTER, AFTON MEGAN (QMHA -R)
Entity type:Individual
Prefix:MRS
First Name:AFTON
Middle Name:MEGAN
Last Name:HOLLISTER
Suffix:
Gender:F
Credentials:QMHA -R
Other - Prefix:
Other - First Name:AFTON
Other - Middle Name:MEG
Other - Last Name:HOLLISTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4101 NE DIVISION ST STE 201
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-4617
Mailing Address - Country:US
Mailing Address - Phone:503-666-6575
Mailing Address - Fax:
Practice Address - Street 1:4101 NE DIVISION ST STE 201
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-4617
Practice Address - Country:US
Practice Address - Phone:503-666-6575
Practice Address - Fax:503-491-3395
Is Sole Proprietor?:No
Enumeration Date:2025-07-30
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25-QMHA-R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist