Healthcare Provider Details

I. General information

NPI: 1003224205
Provider Name (Legal Business Name): NELLIE CICHON CADC 1
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8202 N DENVER AVE
PORTLAND OR
97217-6624
US

IV. Provider business mailing address

10101 SW BARBUR BLVD
PORTLAND OR
97219-5915
US

V. Phone/Fax

Practice location:
  • Phone: 503-285-3200
  • Fax: 503-245-6263
Mailing address:
  • Phone: 503-245-6262
  • Fax: 503-245-6263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number14-04-02
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: