Provider Demographics
NPI:1447621834
Name:NOLDE, ALYSSA MICHELLE (PSYD)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MICHELLE
Last Name:NOLDE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6880 N SENECA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-2538
Mailing Address - Country:US
Mailing Address - Phone:915-525-9655
Mailing Address - Fax:
Practice Address - Street 1:610 SW BROADWAY STE 306
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-3404
Practice Address - Country:US
Practice Address - Phone:503-926-5298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3043103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical