Healthcare Provider Details

I. General information

NPI: 1578754818
Provider Name (Legal Business Name): KIVA MICHELS L.C.S.W., QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37875 JASPER LOWELL RD
JASPER OR
97438-9751
US

IV. Provider business mailing address

37875 JASPER LOWELL RD
JASPER OR
97438-9751
US

V. Phone/Fax

Practice location:
  • Phone: 541-747-1235
  • Fax: 541-747-4722
Mailing address:
  • Phone: 541-747-1235
  • Fax: 541-747-4722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL1547
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: