Provider Demographics
NPI:1730490079
Name:GOLDSMITH-NICKELBERRY, PORTIA
Entity Type:Individual
Prefix:
First Name:PORTIA
Middle Name:
Last Name:GOLDSMITH-NICKELBERRY
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 1:2309 NW 118TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-7425
Mailing Address - Country:US
Mailing Address - Phone:405-608-4198
Mailing Address - Fax:
Practice Address - Street 1:2309 NW 118TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-7425
Practice Address - Country:US
Practice Address - Phone:405-370-8964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK48891041C0700X
171M00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator