Healthcare Provider Details

I. General information

NPI: 1720356298
Provider Name (Legal Business Name): NEIL NICHOLSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

547 E PINE ST STE 201
CENTRAL POINT OR
97502-2444
US

IV. Provider business mailing address

891 OHARE PKWY
MEDFORD OR
97504-4005
US

V. Phone/Fax

Practice location:
  • Phone: 541-423-8151
  • Fax: 541-423-8505
Mailing address:
  • Phone: 541-414-0362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: