Provider Demographics
NPI:1255906558
Name:VAN ALSTINE, NICOLE (CADC-R CRM, PSS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:VAN ALSTINE
Suffix:
Gender:
Credentials:CADC-R CRM, PSS
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADC-R CRM, PSS
Mailing Address - Street 1:340 NW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756
Mailing Address - Country:US
Mailing Address - Phone:541-504-2218
Mailing Address - Fax:541-504-1195
Practice Address - Street 1:1059 NW MADRAS HWY
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754
Practice Address - Country:US
Practice Address - Phone:541-323-5330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTG-24-260101YA0400X
OR24-QMHA-1-004670101YM0800X
OR20-CRM-019175T00000X
OR23-11-10947101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR20-CRM-019Medicaid