Provider Demographics
NPI:1457789661
Name:YOUNG, MICHELLE DIANNE (ND, LAC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIANNE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5806 DUNIWAY AVE
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-1939
Mailing Address - Country:US
Mailing Address - Phone:972-571-6275
Mailing Address - Fax:
Practice Address - Street 1:4670 SW WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-0530
Practice Address - Country:US
Practice Address - Phone:503-646-8575
Practice Address - Fax:503-526-0783
Is Sole Proprietor?:No
Enumeration Date:2013-10-25
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC168160171100000X
OR2000175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500667513Medicaid
OR500681144Medicaid