Provider Demographics
NPI:1396325486
Name:MARTIN, NICOLE RENEE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RENEE
Other - Last Name:MASCIOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21420 STEVENS RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-9629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1550 NE WILLIAMSON BLVD STE 120
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6091
Practice Address - Country:US
Practice Address - Phone:541-640-5601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician