Provider Demographics
NPI:1417072356
Name:SMALL, NICOLE REYNOLDS (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:REYNOLDS
Last Name:SMALL
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 30TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-7603
Mailing Address - Country:US
Mailing Address - Phone:310-210-8662
Mailing Address - Fax:
Practice Address - Street 1:1005 S 3RD ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-4301
Practice Address - Country:US
Practice Address - Phone:360-419-3612
Practice Address - Fax:360-419-3605
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW183841041C0700X
CAPPSC #0600342541041S0200X
WARC00058160101Y00000X
WA443673R1041S0200X
WALW 600649721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSIX593OtherDMH