Provider Demographics
NPI:1538603618
Name:HIGGINBOTHAM, MICHAEL PETER II
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PETER
Last Name:HIGGINBOTHAM
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 PITTVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-2948
Mailing Address - Country:US
Mailing Address - Phone:503-298-0249
Mailing Address - Fax:541-630-4767
Practice Address - Street 1:843 PITTVIEW AVE
Practice Address - Street 2:
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-2948
Practice Address - Country:US
Practice Address - Phone:503-298-0249
Practice Address - Fax:541-386-7982
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
ORC6150101YP2500X, 101YM0800X
ORR4989390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500788866Medicaid