Provider Demographics
NPI:1770913121
Name:MULLIGAN, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MULLIGAN
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 1:9370 SW GREENBURG RD
Mailing Address - Street 2:SUITE 601
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5442
Mailing Address - Country:US
Mailing Address - Phone:503-246-5238
Mailing Address - Fax:
Practice Address - Street 1:9370 SW GREENBURG RD
Practice Address - Street 2:SUITE 601
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-5442
Practice Address - Country:US
Practice Address - Phone:503-246-5238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR02-11-56101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)