Provider Demographics
NPI:1508071473
Name:LARAIA, MICHELE TERESA (PHD, PMHNP)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:TERESA
Last Name:LARAIA
Suffix:
Gender:M
Credentials:PHD, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7107 SW LA VIEW DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-3003
Mailing Address - Country:US
Mailing Address - Phone:503-449-6658
Mailing Address - Fax:
Practice Address - Street 1:1715 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1531
Practice Address - Country:US
Practice Address - Phone:503-234-4622
Practice Address - Fax:503-788-6399
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR103TP0016X, 163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
Not Answered163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult