Basic Information
| Provider Information | |||||||||
| NPI: | 1790413821 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICKEL | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | QMHA-R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 NW 5TH ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977561869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415164099 | ||||||||
| FaxNumber: | 5413167422 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 SW 4TH ST STE 302 | ||||||||
| Address2: | |||||||||
| City: | MADRAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977419629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414756575 | ||||||||
| FaxNumber: | 5414756196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2022 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 22-QMHA-R-2636 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.