Provider Demographics
NPI:1396117248
Name:ESTEY, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ESTEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 SE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1146
Mailing Address - Country:US
Mailing Address - Phone:503-517-8663
Mailing Address - Fax:
Practice Address - Street 1:1904 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1146
Practice Address - Country:US
Practice Address - Phone:503-517-8663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-29
Last Update Date:2024-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHPC-001304101Y00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor