Provider Demographics
NPI:1154801827
Name:FELLENZ, NICOLE (LPC, ATR)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FELLENZ
Suffix:
Gender:F
Credentials:LPC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 NW HOYT ST STE 407
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2787
Mailing Address - Country:US
Mailing Address - Phone:971-407-3930
Mailing Address - Fax:
Practice Address - Street 1:3415 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3371
Practice Address - Country:US
Practice Address - Phone:503-234-9591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORC6958101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health