Provider Demographics
NPI:1427493675
Name:WILLSON, NANCY
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:
Last Name:WILLSON
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 1:1400 SW 5TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5537
Mailing Address - Country:US
Mailing Address - Phone:503-494-8417
Mailing Address - Fax:503-494-4455
Practice Address - Street 1:335 SE 8TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4246
Practice Address - Country:US
Practice Address - Phone:503-681-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-01
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ORL83941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator