Healthcare Provider Details

I. General information

NPI: 1205084845
Provider Name (Legal Business Name): NICKY CALLICOTTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICKY MCLEAN

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36860 INDUSTRIAL WAY
SANDY OR
97055-7371
US

IV. Provider business mailing address

PO BOX 3777
PORTLAND OR
97208-3777
US

V. Phone/Fax

Practice location:
  • Phone: 503-826-0206
  • Fax:
Mailing address:
  • Phone: 503-413-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberL11089
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: