Provider Demographics
NPI:1073984035
Name:NIEMANN, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:NIEMANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9633 LEVIN RD NW STE 100
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8132
Mailing Address - Country:US
Mailing Address - Phone:360-698-5883
Mailing Address - Fax:360-809-6002
Practice Address - Street 1:9633 LEVIN RD NW STE 100
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8132
Practice Address - Country:US
Practice Address - Phone:360-698-5883
Practice Address - Fax:360-809-6002
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61446105101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA20118867Medicaid