Healthcare Provider Details

I. General information

NPI: 1669905709
Provider Name (Legal Business Name): NICOLE VIETH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NIKKI VIETH

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3362 UNIVERSITY AVE
WATERLOO IA
50701-2006
US

IV. Provider business mailing address

8915 SW CENTER ST
TIGARD OR
97223-6307
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-6571
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001437
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12062
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: