=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023414463
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEIDI M NICEWANDER CADC III/LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2014
-----------------------------------------------------
Last Update Date | 03/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1438 SE DIVISION ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97202-1140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-548-0346
-----------------------------------------------------
Fax | 503-232-5959
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 211 SE CARUTHERS ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97214-4502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-224-1044
-----------------------------------------------------
Fax | 971-260-0355
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 25-03-30143
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | L6300
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------