Provider Demographics
NPI:1245601798
Name:SAIZ-DELEON, NICOLE LOUISE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LOUISE
Last Name:SAIZ-DELEON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 WHATCOM ST
Mailing Address - Street 2:
Mailing Address - City:UNION GAP
Mailing Address - State:WA
Mailing Address - Zip Code:98903-1244
Mailing Address - Country:US
Mailing Address - Phone:509-949-6291
Mailing Address - Fax:
Practice Address - Street 1:3801 KERN WAY
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-6340
Practice Address - Country:US
Practice Address - Phone:509-574-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60601642103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG 60601642OtherWASHINGTON STATE DEPARTMENT OF HEALTH