Provider Demographics
NPI:1164856555
Name:WHITNEY, MICHELLE JOHNSON (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JOHNSON
Last Name:WHITNEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LESLIE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-8562
Mailing Address - Fax:503-418-5505
Practice Address - Street 1:535 NE 6TH AVE
Practice Address - Street 2:
Practice Address - City:ESTACADA
Practice Address - State:OR
Practice Address - Zip Code:97023-9312
Practice Address - Country:US
Practice Address - Phone:503-630-8550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4949104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500663254Medicaid