Provider Demographics
NPI:1497131858
Name:SICILIA, MYRA
Entity Type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:
Last Name:SICILIA
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 1:824 NW 20TH AVE
Mailing Address - Street 2:#204
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1454
Mailing Address - Country:US
Mailing Address - Phone:503-597-8675
Mailing Address - Fax:
Practice Address - Street 1:1720 NW LOVEJOY ST
Practice Address - Street 2:328
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2346
Practice Address - Country:US
Practice Address - Phone:503-597-8675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-07
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist