Provider Demographics
NPI:1306197561
Name:SANDERS-MASSINGALE, MICAH
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:SANDERS-MASSINGALE
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 1:4428 SE FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3258
Mailing Address - Country:US
Mailing Address - Phone:217-412-6583
Mailing Address - Fax:
Practice Address - Street 1:2811 NE 139TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2724
Practice Address - Country:US
Practice Address - Phone:360-574-5247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14073235Z00000X
WALL 60401896235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist