Healthcare Provider Details

I. General information

NPI: 1366645731
Provider Name (Legal Business Name): MICHELE HISLOP BA, QMHA, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELE HISLOP

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 NE EVANS ST
MCMINNVILLE OR
97128-4628
US

IV. Provider business mailing address

633 NE 8TH ST
MCMINNVILLE OR
97128-3911
US

V. Phone/Fax

Practice location:
  • Phone: 503-472-4020
  • Fax:
Mailing address:
  • Phone: 503-560-0446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number10968
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: