Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist | 10378251 | OR |
NPI | 1093052912 |
---|---|
Provider Name | Mr. Todd L. Nicholson |
First Address | Portland, OR 97202-3835 |
Second Address | Portland, OR 97202-3835 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/01/2013 |
Last Update Date | 11/01/2013 |