Provider Demographics
NPI:1043786460
Name:MICHAEL, REX
Entity type:Individual
Prefix:
First Name:REX
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 SE 15TH AVE LOWR UNIT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-2205
Mailing Address - Country:US
Mailing Address - Phone:661-476-4279
Mailing Address - Fax:
Practice Address - Street 1:12636 SE STARK ST BLDG J
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1058
Practice Address - Country:US
Practice Address - Phone:661-476-4279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2025-03-20
Deactivation Date:2024-12-05
Deactivation Code:
Reactivation Date:2025-03-18
Provider Licenses
StateLicense IDTaxonomies
ORR10483101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health