Basic Information
| Provider Information | |||||||||
| NPI: | 1760707350 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLAS | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANDERSON | ||||||||
| OtherFirstName: | KATHRYN | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2645 PORTLAND RD NE | ||||||||
| Address2: | STE 120 | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973010198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033905637 | ||||||||
| FaxNumber: | 5033933135 | ||||||||
| Practice Location | |||||||||
| Address1: | 2645 PORTLAND RD NE | ||||||||
| Address2: | STE 120 | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973010198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033905637 | ||||||||
| FaxNumber: | 5033933135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2010 | ||||||||
| LastUpdateDate: | 12/07/2012 | ||||||||
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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 | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.