Provider Demographics
NPI:1093052912
Name:NICHOLSON, TODD L (MS)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:L
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 SE MILWAUKIE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3835
Mailing Address - Country:US
Mailing Address - Phone:503-314-7801
Mailing Address - Fax:971-544-7303
Practice Address - Street 1:3701 SE MILWAUKIE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3835
Practice Address - Country:US
Practice Address - Phone:503-314-7801
Practice Address - Fax:971-544-7303
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10378251103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool