Provider Demographics
NPI:1184487787
Name:WAVERS, NICHOLAS B (PCA)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:B
Last Name:WAVERS
Suffix:
Gender:M
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 NE ORENCO STATION LOOP APT 621
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-4503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11740 SW 68TH PKWY STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-9058
Practice Address - Country:US
Practice Address - Phone:425-477-4216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR8909101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health