Provider Demographics
NPI:1124496542
Name:MICKELSON-WILLIS, CHELSEA ELISE
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:ELISE
Last Name:MICKELSON-WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 NW LOVEJOY ST
Mailing Address - Street 2:APT 214
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3173
Mailing Address - Country:US
Mailing Address - Phone:303-250-8607
Mailing Address - Fax:
Practice Address - Street 1:2240 NW LOVEJOY ST
Practice Address - Street 2:APT 214
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3173
Practice Address - Country:US
Practice Address - Phone:303-250-8607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor