Provider Demographics
NPI:1720566821
Name:STIVER, NICOLE LIND
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LIND
Last Name:STIVER
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:PO BOX 12723
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-0723
Mailing Address - Country:US
Mailing Address - Phone:206-427-0304
Mailing Address - Fax:
Practice Address - Street 1:10500 SE 26TH AVE APT D16
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-9615
Practice Address - Country:US
Practice Address - Phone:206-427-0304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4744101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health