Provider Demographics
NPI:1669905709
Name:VIETH, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:VIETH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NIKKI
Other - Middle Name:
Other - Last Name:VIETH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8915 SW CENTER ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3362 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-2006
Practice Address - Country:US
Practice Address - Phone:319-235-6571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001437101YM0800X
IA12062101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAXQW496AD2124OtherBLUECROSS BLUESHIELD