=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124941141
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLUS BLAIR CADC I
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2026
-----------------------------------------------------
Last Update Date | 08/04/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 920 SW FRAZER AVE
-----------------------------------------------------
City | PENDLETON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97801-2800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-276-1022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2426 SW NYE AVE
-----------------------------------------------------
City | PENDLETON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97801-4371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-310-7250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 18-03-09
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------