Provider Demographics
NPI:1497159461
Name:AMSDEN, NIKI DESANTO (PHD)
Entity Type:Individual
Prefix:DR
First Name:NIKI
Middle Name:DESANTO
Last Name:AMSDEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:NIKI
Other - Middle Name:ANDREA
Other - Last Name:DESANTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:272 MEDICAL LOOP
Mailing Address - Street 2:SUITE E
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471
Mailing Address - Country:US
Mailing Address - Phone:541-440-3532
Mailing Address - Fax:541-440-3554
Practice Address - Street 1:2700 STEWART PARKWAY
Practice Address - Street 2:ANNEX B
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471
Practice Address - Country:US
Practice Address - Phone:541-440-3532
Practice Address - Fax:541-440-3554
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X
CAPSY 12507103TC0700X
OR2464103TR0400X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500679588Medicaid