Healthcare Provider Details

I. General information

NPI: 1952127839
Provider Name (Legal Business Name): NICOLE PANOWICZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11740 SW 68TH PKWY STE 200
TIGARD OR
97223-9058
US

IV. Provider business mailing address

2355 STATE ST
SALEM OR
97301-4541
US

V. Phone/Fax

Practice location:
  • Phone: 971-352-6971
  • Fax:
Mailing address:
  • Phone: 971-678-7031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberA15477
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: