Individual
MS. MY'KELL MIRACLE GIO'VONNI
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
RBT/QMHA
Contact information
Practice address
2808 SE BALFOUR ST, MILWAUKIE, OR 97222-6426
(503) 659-2575
(503) 659-5182
Mailing address
3587 HEATHROW WAY, MEDFORD, OR 97504-4004
(541) 858-8170
(541) 858-8167
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
106S00000X
OR
Other
Enumeration date
08/14/2023
Last updated
10/16/2023
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