Provider Demographics
NPI:1770705790
Name:HENDRICKS, NICHOLE (LCP)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 870
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97075
Mailing Address - Country:US
Mailing Address - Phone:541-296-5400
Mailing Address - Fax:
Practice Address - Street 1:119 E 2ND STREET
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058
Practice Address - Country:US
Practice Address - Phone:541-296-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1928101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional