Provider Demographics
NPI:1518558428
Name:TILLERY, MYCHAL QUINTE
Entity Type:Individual
Prefix:
First Name:MYCHAL
Middle Name:QUINTE
Last Name:TILLERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9320 SW BARBUR BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5499
Mailing Address - Country:US
Mailing Address - Phone:503-222-9661
Mailing Address - Fax:503-224-5960
Practice Address - Street 1:9320 SW BARBUR BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-5499
Practice Address - Country:US
Practice Address - Phone:503-222-9661
Practice Address - Fax:503-224-5960
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health