Basic Information
| Provider Information | |||||||||
| NPI: | 1588855910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICKEL | ||||||||
| FirstName: | MARY-BETH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | L.P.C, M.A., D.V.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1234 | ||||||||
| Address2: | |||||||||
| City: | SAINT HELENS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970518234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033975211 | ||||||||
| FaxNumber: | 5033975373 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 SW COAST HWY STE 306 | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973655241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412648808 | ||||||||
| FaxNumber: | 5412648808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2007 | ||||||||
| LastUpdateDate: | 08/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | RR0502 | OR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 174M00000X | 4404 | OR | N | Other Service Providers | Veterinarian | 101YM0800X | C2151 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 123190 | 05 | OR | MEDICAID |