Provider Demographics
NPI:1508195629
Name:WICKLEIN, NICHOLE C
Entity Type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:C
Last Name:WICKLEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:NICHOLE
Other - Middle Name:C
Other - Last Name:WYMASTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:1800 112TH AVE NE STE 240W
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-2965
Mailing Address - Country:US
Mailing Address - Phone:425-214-6739
Mailing Address - Fax:425-502-9681
Practice Address - Street 1:1800 112TH AVE NE STE 240W
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-2965
Practice Address - Country:US
Practice Address - Phone:425-214-6739
Practice Address - Fax:425-502-9681
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-19
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60094600101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health