Healthcare Provider Details

I. General information

NPI: 1750961751
Provider Name (Legal Business Name): NICOLE COLLEEN GARDEA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 NE 2ND ST
GRESHAM OR
97030-7514
US

IV. Provider business mailing address

211 SE CARUTHERS ST
PORTLAND OR
97214-4502
US

V. Phone/Fax

Practice location:
  • Phone: 971-274-3757
  • Fax: 503-912-5740
Mailing address:
  • Phone: 503-224-1044
  • Fax: 971-260-0335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25-CRM-4562
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: