Provider Demographics
NPI:1093055840
Name:GILL, MICHAEL IAN (LAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:IAN
Last Name:GILL
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 SE 7TH AVE
Mailing Address - Street 2:15248
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97293-0856
Mailing Address - Country:US
Mailing Address - Phone:971-279-3591
Mailing Address - Fax:
Practice Address - Street 1:124 SW YAMHILL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-3019
Practice Address - Country:US
Practice Address - Phone:971-279-3591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7888225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist