Provider Demographics
NPI:1558149138
Name:GIUSTO, NICOLE L
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:GIUSTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13203 SE 172ND AVE STE. 166 #(141)
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086
Mailing Address - Country:US
Mailing Address - Phone:503-908-5524
Mailing Address - Fax:
Practice Address - Street 1:13100 SE SUNNYSIDE RD STE B
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015
Practice Address - Country:US
Practice Address - Phone:503-659-3480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-15
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
ORR8564101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty