Basic Information
| Provider Information | |||||||||
| NPI: | 1477621464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FITZ | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.ED. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2410 SE 121ST AVE | ||||||||
| Address2: | SUITE 216 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972164066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033355975 | ||||||||
| FaxNumber: | 5033355974 | ||||||||
| Practice Location | |||||||||
| Address1: | 2410 SE 121ST AVE | ||||||||
| Address2: | SUITE 216 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972164066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033355975 | ||||||||
| FaxNumber: | 5033355974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 02/14/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.