Healthcare Provider Details

I. General information

NPI: 1417492851
Provider Name (Legal Business Name): MICHAL SIERRA MOORE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHAL DEDRICK LPCA

II. Dates (important events)

Enumeration Date: 12/20/2016
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 NW BETHANY BLVD STE 320
BEAVERTON OR
97006-5238
US

IV. Provider business mailing address

20300 SE MORRISON TER APT F2039
GRESHAM OR
97030-2274
US

V. Phone/Fax

Practice location:
  • Phone: 503-233-5405
  • Fax:
Mailing address:
  • Phone: 650-382-9218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC7904
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberR7792
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: