Provider Demographics
NPI:1568196533
Name:GREENE, NICHOLE RAE (CO 61217566)
Entity Type:Individual
Prefix:MISS
First Name:NICHOLE
Middle Name:RAE
Last Name:GREENE
Suffix:
Gender:F
Credentials:CO 61217566
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3202 S MASON AVE APT D307
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-2295
Mailing Address - Country:US
Mailing Address - Phone:775-400-0299
Mailing Address - Fax:
Practice Address - Street 1:9500 FRONT ST S STE 100
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-9415
Practice Address - Country:US
Practice Address - Phone:253-584-3996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61217566101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)