Provider Demographics
NPI:1083699979
Name:LA VERNE, A. NICOLE (LPC, MAC, CADC III,)
Entity Type:Individual
Prefix:
First Name:A.
Middle Name:NICOLE
Last Name:LA VERNE
Suffix:
Gender:F
Credentials:LPC, MAC, CADC III,
Other - Prefix:
Other - First Name:A.
Other - Middle Name:NICOLE
Other - Last Name:SPIVEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5285 MEADOWS RD STE 170
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-3478
Mailing Address - Country:US
Mailing Address - Phone:503-726-5216
Mailing Address - Fax:
Practice Address - Street 1:5285 MEADOWS RD STE 170
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3478
Practice Address - Country:US
Practice Address - Phone:503-726-5216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR041169U3101YA0400X
ORC1853101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)