Provider Demographics
NPI:1588855910
Name:NICKEL, MARY-BETH (LPC, MA, DVM)
Entity type:Individual
Prefix:
First Name:MARY-BETH
Middle Name:
Last Name:NICKEL
Suffix:
Gender:F
Credentials:LPC, MA, DVM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1234
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-8234
Mailing Address - Country:US
Mailing Address - Phone:503-397-5211
Mailing Address - Fax:503-397-5373
Practice Address - Street 1:1010 SW COAST HWY STE 306
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-5241
Practice Address - Country:US
Practice Address - Phone:541-264-8808
Practice Address - Fax:541-264-8808
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRR0502101YM0800X
OR4404174M00000X
ORC2151101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No174M00000XOther Service ProvidersVeterinarian
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR123190Medicaid