Basic Information
| Provider Information | |||||||||
| NPI: | 1386005973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOX | ||||||||
| FirstName: | NICHOLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PSS, CADC-R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975012756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417721777 | ||||||||
| FaxNumber: | 5417342410 | ||||||||
| Practice Location | |||||||||
| Address1: | 3397 DELTA WATERS RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975045852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417724648 | ||||||||
| FaxNumber: | 5418587593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2016 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 247000000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Health Information | 101YA0400X | T-22-1388 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | ONTRACK | 05 | OR | MEDICAID |