Basic Information
| Provider Information | |||||||||
| NPI: | 1851546139 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARREN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WARREN | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 82819 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972820819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036668832 | ||||||||
| FaxNumber: | 5036698641 | ||||||||
| Practice Location | |||||||||
| Address1: | 1217 NE BURNSIDE RD | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970306722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036668832 | ||||||||
| FaxNumber: | 5036698641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2008 | ||||||||
| LastUpdateDate: | 11/30/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C2218 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 164936 | 05 | OR | MEDICAID |