Basic Information
Provider Information | |||||||||
NPI: | 1336298397 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MURA JOHNSON | ||||||||
FirstName: | MICHELLE | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OTRL | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MURA | ||||||||
OtherFirstName: | MICHELLE | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OTRL | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1126 | ||||||||
Address2: | 610 HIGH STREET | ||||||||
City: | OREGON CITY | ||||||||
State: | OR | ||||||||
PostalCode: | 97045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036578903 | ||||||||
FaxNumber: | 5036504302 | ||||||||
Practice Location | |||||||||
Address1: | 610 HIGH STREET | ||||||||
Address2: |   | ||||||||
City: | OREGON CITY | ||||||||
State: | OR | ||||||||
PostalCode: | 97045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036578903 | ||||||||
FaxNumber: | 5036504302 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/09/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 983676 | OR | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 8397937 | 05 | WA |   | MEDICAID | 071477 | 05 | OR |   | MEDICAID |