Provider Demographics
NPI:1720600349
Name:REILLY, MICHELLE A (LPC INTERN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:REILLY
Suffix:
Gender:F
Credentials:LPC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7320 SW HUNZIKER RD STE 204
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-2301
Mailing Address - Country:US
Mailing Address - Phone:971-238-2664
Mailing Address - Fax:
Practice Address - Street 1:7320 SW HUNZIKER RD STE 204
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-2301
Practice Address - Country:US
Practice Address - Phone:971-238-2664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional