Healthcare Provider Details

I. General information

NPI: 1275804221
Provider Name (Legal Business Name): NATHAN LEE FORDHAM LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2012
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4422 NE DEVILS LAKE BLVD SUITE 2
LINCOLN CITY OR
97367-5000
US

IV. Provider business mailing address

36 SW NYE ST
NEWPORT OR
97365-3821
US

V. Phone/Fax

Practice location:
  • Phone: 541-265-4196
  • Fax: 541-994-1882
Mailing address:
  • Phone: 541-265-4179
  • Fax: 541-574-6252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC3541
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: