Basic Information
| Provider Information | |||||||||
| NPI: | 1598802274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ALICIA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CADC 1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5224 SE 92ND AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972663824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9715064816 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3910 SE STARK ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972143241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032358655 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 08/05/2016 | ||||||||
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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 | 101YA0400X | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 372600000X | N | Nursing Service Related Providers | Adult Companion | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.