Provider Demographics
NPI:1316620578
Name:GIO'VONNI, MY'KELL MIRACLE (RBT/QMHA)
Entity type:Individual
Prefix:MS
First Name:MY'KELL
Middle Name:MIRACLE
Last Name:GIO'VONNI
Suffix:
Gender:F
Credentials:RBT/QMHA
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Mailing Address - Street 1:3587 HEATHROW WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4004
Mailing Address - Country:US
Mailing Address - Phone:541-858-8170
Mailing Address - Fax:541-858-8167
Practice Address - Street 1:2808 SE BALFOUR ST
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6426
Practice Address - Country:US
Practice Address - Phone:503-659-2575
Practice Address - Fax:503-659-5182
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-10-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OR106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician