Provider Demographics
NPI:1730750050
Name:INESS, NICHOLE
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:INESS
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:PO BOX 20674
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97307-0674
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:465 COMMERCIAL ST NE # 150
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3414
Practice Address - Country:US
Practice Address - Phone:503-362-2780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-20-344101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT-20-344OtherMHACBO