Basic Information
| Provider Information | |||||||||
| NPI: | 1275707960 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOMLITAS | ||||||||
| FirstName: | MISTY | ||||||||
| MiddleName: | MCARTHUR | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 82819 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972820819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032335405 | ||||||||
| FaxNumber: | 5032332694 | ||||||||
| Practice Location | |||||||||
| Address1: | 12636 SE STARK ST | ||||||||
| Address2: | PLAZA 125, BUILDING J | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972331058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032534600 | ||||||||
| FaxNumber: | 5032534609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2008 | ||||||||
| LastUpdateDate: | 09/08/2009 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 164936 | 05 | OR | MEDICAID | R0000WDBCH | 01 | OR | MEDICARE GROUP | OTHER |