Healthcare Provider Details

I. General information

NPI: 1235912742
Provider Name (Legal Business Name): MICHELLE MAYA MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 SE 182ND AVE
GRESHAM OR
97030-5028
US

IV. Provider business mailing address

619 NW 6TH AVE FL 5
PORTLAND OR
97209-3991
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-5488
  • Fax:
Mailing address:
  • Phone: 503-988-4753
  • Fax: 503-988-3015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: