Basic Information
| Provider Information | |||||||||
| NPI: | 1881054633 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHAELS | ||||||||
| FirstName: | BRYAN | ||||||||
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| Credential: | QMHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 SW RAMSEY AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419564946 | ||||||||
| FaxNumber: | 5419565453 | ||||||||
| Practice Location | |||||||||
| Address1: | 1913 MEADE ST | ||||||||
| Address2: | |||||||||
| City: | NORTH BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974593432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417564508 | ||||||||
| FaxNumber: | 5417564550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2016 | ||||||||
| LastUpdateDate: | 04/25/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | N | Other Service Providers | Community Health Worker | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.