Provider Demographics
NPI:1316117047
Name:NIELSEN, MARCIA MARIE
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:MARIE
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10345 NE CLACKAMAS ST APT 16
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3997
Mailing Address - Country:US
Mailing Address - Phone:503-408-7683
Mailing Address - Fax:
Practice Address - Street 1:412 SW 12TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2329
Practice Address - Country:US
Practice Address - Phone:503-228-7134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-10
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000043616N6363LP0808X
101YM0800X
OR163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health