1487108460 NPI number — NICOLE PROPHET MS, LPC

Table of content: NICOLE PROPHET MS, LPC (NPI 1487108460)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487108460 NPI number — NICOLE PROPHET MS, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROPHET
Provider First Name:
NICOLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PROPHET
Provider Other First Name:
COLE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, LPC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1487108460
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7901 SE POWELL BLVD, STE B
Provider Second Line Business Mailing Address:
#111
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97206-2331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
971-865-3573
Provider Business Mailing Address Fax Number:
971-999-0908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7227 SE THORBURN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97215-1434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-865-3573
Provider Business Practice Location Address Fax Number:
971-999-0908
Provider Enumeration Date:
08/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101Y00000X , with the licence number: C6307 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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