Provider Demographics
NPI:1053757880
Name:REVELL, MICHAEL RUSSELL (LPC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RUSSELL
Last Name:REVELL
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 SW TROY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-1664
Mailing Address - Country:US
Mailing Address - Phone:503-479-8605
Mailing Address - Fax:971-339-7047
Practice Address - Street 1:3811 SW TROY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-1664
Practice Address - Country:US
Practice Address - Phone:503-479-8605
Practice Address - Fax:971-339-7047
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60961479101Y00000X
OR6991101Y00000X, 101YP2500X
ORR6261101Y00000X, 101YM0800X
ORC6991101Y00000X, 101YP2500X, 101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator