Healthcare Provider Details

I. General information

NPI: 1770154379
Provider Name (Legal Business Name): MICHELLE ALEXANDRIA GOWAN YANG LPC INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5119 RIVER RD N
KEIZER OR
97303-5349
US

IV. Provider business mailing address

365 SABRA LN NE APT 303
SALEM OR
97301-2312
US

V. Phone/Fax

Practice location:
  • Phone: 503-362-7487
  • Fax:
Mailing address:
  • Phone: 775-934-3093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberR6913
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: