Provider Demographics
NPI:1386005973
Name:FOX, NICHOLE DAWN (PSS, CADC-R)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:DAWN
Last Name:FOX
Suffix:
Gender:F
Credentials:PSS, CADC-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-2756
Mailing Address - Country:US
Mailing Address - Phone:541-772-1777
Mailing Address - Fax:541-734-2410
Practice Address - Street 1:300 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-2756
Practice Address - Country:US
Practice Address - Phone:541-772-1777
Practice Address - Fax:541-858-7593
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247000000X
ORT-22-1388101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORONTRACKMedicaid