Provider Demographics
NPI:1750752010
Name:NELSON, PAUL O (CADC CANDIDATE/QMHP)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:O
Last Name:NELSON
Suffix:
Gender:M
Credentials:CADC CANDIDATE/QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19474 SE 38TH WAY
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:97607
Mailing Address - Country:US
Mailing Address - Phone:650-430-7285
Mailing Address - Fax:
Practice Address - Street 1:17645 NW SAINT HELENS RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97231
Practice Address - Country:US
Practice Address - Phone:503-621-1069
Practice Address - Fax:503-621-0200
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
CAIMF80598106H00000X
CA56125106H00000X
ORT-18-281101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500746319Medicaid
OR500747233Medicaid