Provider Demographics
NPI:1083133490
Name:JOHNSON, NICOLE REBECCA LIU (PSYD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:REBECCA LIU
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:NIKKI
Other - Middle Name:REBECCA LIU
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:20826 2ND AVE W
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-7256
Mailing Address - Country:US
Mailing Address - Phone:925-548-2863
Mailing Address - Fax:
Practice Address - Street 1:20826 2ND AVE W
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-7256
Practice Address - Country:US
Practice Address - Phone:925-548-2863
Practice Address - Fax:925-548-2863
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-18
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60722639103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103TF0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic