Provider Demographics
NPI:1508355850
Name:PAGE, NICHOLE LYNN (CDPT)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:LYNN
Last Name:PAGE
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1530
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-0265
Mailing Address - Country:US
Mailing Address - Phone:360-533-9750
Mailing Address - Fax:
Practice Address - Street 1:1016 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:WA
Practice Address - Zip Code:98577-2631
Practice Address - Country:US
Practice Address - Phone:360-942-3271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60786018101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)