Provider Demographics
NPI:1053595785
Name:ABBOTT, MIYA GRAY (LICENSED CLINICAL SO)
Entity type:Individual
Prefix:MISS
First Name:MIYA
Middle Name:GRAY
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:LICENSED CLINICAL SO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 E BURNSIDE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1689
Mailing Address - Country:US
Mailing Address - Phone:503-951-0328
Mailing Address - Fax:
Practice Address - Street 1:2304 E. BUMSIDE ST.
Practice Address - Street 2:SUITE 201
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214
Practice Address - Country:US
Practice Address - Phone:503-951-0328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
ORL49141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500637536Medicaid