Provider Demographics
NPI:1184023145
Name:KNIGHT, MYKEL EVAN
Entity Type:Individual
Prefix:
First Name:MYKEL
Middle Name:EVAN
Last Name:KNIGHT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MYKEL
Other - Middle Name:C
Other - Last Name:WENTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8915 SW CENTER ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6307
Mailing Address - Country:US
Mailing Address - Phone:503-726-3690
Mailing Address - Fax:
Practice Address - Street 1:8915 SW CENTER ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6307
Practice Address - Country:US
Practice Address - Phone:503-726-3690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health