Healthcare Provider Details

I. General information

NPI: 1083527360
Provider Name (Legal Business Name): SHELLY NICOL, PSYD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4631 SE 62ND AVE
PORTLAND OR
97206-4603
US

IV. Provider business mailing address

5441 S MACADAM AVE STE A
PORTLAND OR
97239-3822
US

V. Phone/Fax

Practice location:
  • Phone: 808-381-5834
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: SHELLY NICOL
Title or Position: PSYCHOLOGIST
Credential: PSYD
Phone: 808-381-5834