Basic Information
| Provider Information | |||||||||
| NPI: | 1619043833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EHRMANTROUT | ||||||||
| FirstName: | NIKKI | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS QMHP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FULKS | ||||||||
| OtherFirstName: | NICHOLE | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2101 | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417268819 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 576 OLIVE STREET SUITE 307 | ||||||||
| Address2: | DIRECTION SERVICE COUNSELING CENTER | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413447303 | ||||||||
| FaxNumber: | 5416866283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 037759 | 05 | OR | MEDICAID |