Provider Demographics
NPI:1568066744
Name:LONGHOFER, NICOLE LEA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEA
Last Name:LONGHOFER
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 1:18211 RAMPART DR SE
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-9018
Mailing Address - Country:US
Mailing Address - Phone:330-488-5297
Mailing Address - Fax:
Practice Address - Street 1:9330 59TH AVE SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2858
Practice Address - Country:US
Practice Address - Phone:253-620-5015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-28
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health