Healthcare Provider Details

I. General information

NPI: 1538823505
Provider Name (Legal Business Name): NICO AGUILAR SHANK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 01/25/2025
Certification Date: 01/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12655 SW CENTER ST STE 100
BEAVERTON OR
97005-1600
US

IV. Provider business mailing address

7915 N HEREFORD AVE
PORTLAND OR
97203-3437
US

V. Phone/Fax

Practice location:
  • Phone: 503-828-3402
  • Fax:
Mailing address:
  • Phone: 971-645-5279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberA14715
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: