Provider Demographics
NPI:1003115114
Name:OSARA, MICHELLE NICOLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLE
Last Name:OSARA
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 1:565 UNION ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2477
Mailing Address - Country:US
Mailing Address - Phone:503-409-9597
Mailing Address - Fax:
Practice Address - Street 1:565 UNION ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301
Practice Address - Country:US
Practice Address - Phone:503-409-9597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-15
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR171M00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR122994Medicaid