Provider Demographics
NPI:1821179938
Name:NIGHTENGALE, CAROL LYNN (LCSW, PC)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNN
Last Name:NIGHTENGALE
Suffix:
Gender:F
Credentials:LCSW, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 N MAIN AVE
Mailing Address - Street 2:SUITE 216
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7242
Mailing Address - Country:US
Mailing Address - Phone:503-669-1095
Mailing Address - Fax:503-665-3299
Practice Address - Street 1:320 N MAIN AVE
Practice Address - Street 2:SUITE 216
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7242
Practice Address - Country:US
Practice Address - Phone:503-669-1095
Practice Address - Fax:503-665-3299
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR108585Medicare ID - Type UnspecifiedPROVIDER #