Provider Demographics
NPI:1225129950
Name:MICHAELS, MARCIA
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:MICHAELS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82819
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97282-0819
Mailing Address - Country:US
Mailing Address - Phone:503-233-5405
Mailing Address - Fax:503-233-2692
Practice Address - Street 1:7455 SW BEVELAND RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8610
Practice Address - Country:US
Practice Address - Phone:503-624-2600
Practice Address - Fax:503-624-7752
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00219106H00000X
ORT1017106H00000X
CA50275106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist