Provider Demographics
NPI:1760707350
Name:NICHOLAS, KATHRYN LYNN
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:LYNN
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KATHRYN
Other - Middle Name:LYNN
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2645 PORTLAND RD NE
Mailing Address - Street 2:STE 120
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-0198
Mailing Address - Country:US
Mailing Address - Phone:503-390-5637
Mailing Address - Fax:503-393-3135
Practice Address - Street 1:2645 PORTLAND RD NE
Practice Address - Street 2:STE 120
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0198
Practice Address - Country:US
Practice Address - Phone:503-390-5637
Practice Address - Fax:503-393-3135
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
ORT0943106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist