=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972494870
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICK MARSHALL PCA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2025
-----------------------------------------------------
Last Update Date | 07/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 SW BRANTLEY DR
-----------------------------------------------------
City | WINSTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97496-4526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-679-0366
-----------------------------------------------------
Fax | 541-679-4821
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 SW BRANTLEY DR
-----------------------------------------------------
City | WINSTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97496-4526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-679-0366
-----------------------------------------------------
Fax | 541-679-4821
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------