Healthcare Provider Details

I. General information

NPI: 1922451137
Provider Name (Legal Business Name): NICOLE BERNEICE CALVERY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2016
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 RIVERBEND DR
SPRINGFIELD OR
97477-8800
US

IV. Provider business mailing address

3415 SE POWELL BLVD
PORTLAND OR
97202-3371
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-2185
  • Fax: 541-222-2194
Mailing address:
  • Phone: 503-234-9591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number25-QMHP-R-3666
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: