Provider Demographics
NPI:1467436352
Name:NICHOLSON, BEVERLY ANNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:ANNE
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 AMES CT
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-1874
Mailing Address - Country:US
Mailing Address - Phone:503-873-3242
Mailing Address - Fax:
Practice Address - Street 1:452 WELCH ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-1934
Practice Address - Country:US
Practice Address - Phone:503-873-8740
Practice Address - Fax:503-874-2470
Is Sole Proprietor?:No
Enumeration Date:2005-12-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1474103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR113524Medicare ID - Type UnspecifiedPROVIDER IDENTIFICATION N