Basic Information
| Provider Information | |||||||||
| NPI: | 1417492851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | MICHAL | ||||||||
| MiddleName: | SIERRA | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEDRICK | ||||||||
| OtherFirstName: | MICHAL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 20300 SE MORRISON TER APT F2039 | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970302274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503829218 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1500 NW BETHANY BLVD STE 320 | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970065238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032335405 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2016 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 101Y00000X | R7792 | OR | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.