Provider Demographics
NPI:1912332651
Name:NICKERSON, TEVER D (LPC)
Entity Type:Individual
Prefix:MS
First Name:TEVER
Middle Name:D
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 SE MILWAUKIE AVE STE E
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3835
Mailing Address - Country:US
Mailing Address - Phone:503-784-2377
Mailing Address - Fax:
Practice Address - Street 1:3701 SE MILWAUKIE AVE STE E
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3835
Practice Address - Country:US
Practice Address - Phone:503-784-2377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3163101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional