MEDICARE: MICHAEL GORDON MAKINSTER LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	C1085	OR

General Provider Information

NPI Number	:	1659473015
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL GORDON MAKINSTER LPC

Provider Business Mailing Address
First Line	:	7018 NE HASSALO ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97213-5439
Country	:	US
Telephone Number	:	503-636-4176
Fax Number	:

Provider Business Practice Location Address
First Line	:	8815 NE GLISAN ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97220-5861
Country	:	US
Telephone Number	:	971-409-9252
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2006
Last Update Date	:	07/08/2007

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