Basic Information
| Provider Information | |||||||||
| NPI: | 1063648814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCNAMARA | ||||||||
| FirstName: | NICK | ||||||||
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| Credential: | QMHP. CADC II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1003 E MAIN ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413264905 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16 S PEACH ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975012945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417791282 | ||||||||
| FaxNumber: | 5417791282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2009 | ||||||||
| LastUpdateDate: | 04/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.