Provider Demographics
NPI:1699169193
Name:MCNICHOLS, MICHAEL ANDREW
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANDREW
Last Name:MCNICHOLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 NE 30TH PL
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-2103
Mailing Address - Country:US
Mailing Address - Phone:503-899-9231
Mailing Address - Fax:
Practice Address - Street 1:707 NE COUCH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2922
Practice Address - Country:US
Practice Address - Phone:503-542-4603
Practice Address - Fax:503-233-6093
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker