Basic Information
| Provider Information | |||||||||
| NPI: | 1760859052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MIKILAH | ||||||||
| MiddleName: | TERAE | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11035 NE SANDY BLVD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972202553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032584200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 831 NW COUNCIL DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970303725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032584600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2015 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | T1770 | OR | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.