Basic Information
| Provider Information | |||||||||
| NPI: | 1366754186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRIPLETT | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | CADC II | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17818 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973057818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033632021 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3878 BEVERLY AVE NE STE 5 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973051335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033632021 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2010 | ||||||||
| LastUpdateDate: | 12/15/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 12-09-73 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 263634042 | 05 | OR | MEDICAID |