Provider Demographics
NPI:1215516828
Name:ERTSGAARD, NICHOLAS B (MS CF-SLP)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:B
Last Name:ERTSGAARD
Suffix:
Gender:M
Credentials:MS CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5191 SEEGER LN SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-1986
Mailing Address - Country:US
Mailing Address - Phone:503-983-5573
Mailing Address - Fax:
Practice Address - Street 1:3220 LIBERTY RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4560
Practice Address - Country:US
Practice Address - Phone:503-749-9743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17386235Z00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty