Provider Demographics
NPI:1346628476
Name:CASTILLO-ELIZONDO, MICHELLE (QHMA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CASTILLO-ELIZONDO
Suffix:
Gender:F
Credentials:QHMA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:ELIZONDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:QMHA
Mailing Address - Street 1:3180 CENTER ST NE
Mailing Address - Street 2:STE 3360
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4532
Mailing Address - Country:US
Mailing Address - Phone:503-432-5866
Mailing Address - Fax:503-361-2666
Practice Address - Street 1:3180 CENTER ST NE
Practice Address - Street 2:STE 3360
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4532
Practice Address - Country:US
Practice Address - Phone:503-432-5866
Practice Address - Fax:503-361-2666
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORA5855Medicaid