Basic Information
| Provider Information | |||||||||
| NPI: | 1477623072 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHEL | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16470 SE PLEASANT VALLEY PKWY | ||||||||
| Address2: | |||||||||
| City: | HAPPY VALLEY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970864393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039983415 | ||||||||
| FaxNumber: | 5039269313 | ||||||||
| Practice Location | |||||||||
| Address1: | 4605 NE FREMONT ST STE 210F | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972131707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039983415 | ||||||||
| FaxNumber: | 5036591994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | LMFTT0406 | OR | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 164936 | 05 | OR | MEDICAID |