Provider Demographics
NPI:1598802274
Name:KING, NICOLE ALICIA (CADC 1)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ALICIA
Last Name:KING
Suffix:
Gender:F
Credentials:CADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5224 SE 92ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-3824
Mailing Address - Country:US
Mailing Address - Phone:971-506-4816
Mailing Address - Fax:
Practice Address - Street 1:3910 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3241
Practice Address - Country:US
Practice Address - Phone:503-235-8655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
372600000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No372600000XNursing Service Related ProvidersAdult Companion
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health