Provider Demographics
NPI:1710458484
Name:MICKOLA, OLIVIA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:MICKOLA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 SE WASHINGTON ST STE 102
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7647
Mailing Address - Country:US
Mailing Address - Phone:503-654-1014
Mailing Address - Fax:503-654-1148
Practice Address - Street 1:2305 SE WASHINGTON ST STE 102
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7647
Practice Address - Country:US
Practice Address - Phone:503-654-1014
Practice Address - Fax:503-654-1148
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR015940235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR015940OtherBSPA