Provider Demographics
NPI:1821134016
Name:NICHOLS, LISA MARIE (QMHA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7028 N MOBILE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-5744
Mailing Address - Country:US
Mailing Address - Phone:503-552-5105
Mailing Address - Fax:
Practice Address - Street 1:412 SW 12TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2329
Practice Address - Country:US
Practice Address - Phone:503-552-5105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator