Healthcare Provider Details

I. General information

NPI: 1801548136
Provider Name (Legal Business Name): MICHELLE CARPENTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2022
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S MAIN ST
LEBANON OR
97355-3109
US

IV. Provider business mailing address

PO BOX 100
ALBANY OR
97321-0031
US

V. Phone/Fax

Practice location:
  • Phone: 541-451-2631
  • Fax:
Mailing address:
  • Phone: 541-451-2631
  • Fax: 541-812-8807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: