Healthcare Provider Details

I. General information

NPI: 1346278132
Provider Name (Legal Business Name): CAROL STEVENS NICHOLL LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CARO NICHOLL

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 10/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 MADRONA AVE S
SALEM OR
97302-4061
US

IV. Provider business mailing address

1640 MADRONA AVE S
SALEM OR
97302-4061
US

V. Phone/Fax

Practice location:
  • Phone: 503-990-1220
  • Fax:
Mailing address:
  • Phone: 503-990-1220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number5133
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: