Healthcare Provider Details

I. General information

NPI: 1568292977
Provider Name (Legal Business Name): MAYAN NICOLE MCDERMOTT
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 NE IRVING ST STE 440
PORTLAND OR
97232-4208
US

IV. Provider business mailing address

1551 PEARL ST
EUGENE OR
97401-4010
US

V. Phone/Fax

Practice location:
  • Phone: 541-517-9733
  • Fax:
Mailing address:
  • Phone: 541-517-9733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberR9942
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: