Provider Demographics
NPI:1851546139
Name:WARREN, NICOLE E (MA)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:E
Last Name:WARREN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:E
Other - Last Name:WARREN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 82819
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97282-0819
Mailing Address - Country:US
Mailing Address - Phone:503-666-8832
Mailing Address - Fax:503-669-8641
Practice Address - Street 1:1217 NE BURNSIDE RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-6722
Practice Address - Country:US
Practice Address - Phone:503-666-8832
Practice Address - Fax:503-669-8641
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-30
Last Update Date:2008-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2218101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid