Basic Information
| Provider Information | |||||||||
| NPI: | 1225528078 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLARD | ||||||||
| FirstName: | LETICIA | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | MILLARD | ||||||||
| OtherFirstName: | TISHA | ||||||||
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| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10942 SW CELESTE LN APT 201 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972257116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413597878 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2645 PORTLAND RD NE STE 120 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973010200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033905637 | ||||||||
| FaxNumber: | 5033933135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2018 | ||||||||
| LastUpdateDate: | 05/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.