Provider Demographics
NPI:1205084845
Name:CALLICOTTE, NICKY
Entity type:Individual
Prefix:
First Name:NICKY
Middle Name:
Last Name:CALLICOTTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICKY
Other - Middle Name:
Other - Last Name:MCLEAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3777
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3777
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:
Practice Address - Street 1:36860 INDUSTRIAL WAY
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:OR
Practice Address - Zip Code:97055-7371
Practice Address - Country:US
Practice Address - Phone:503-826-0206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ORL11089104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator