Provider Demographics
NPI:1578624565
Name:LESSARD, NICHOLE MICHELLE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MICHELLE
Last Name:LESSARD
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16308 TIGER MOUNTAIN RD SE
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-8339
Mailing Address - Country:US
Mailing Address - Phone:425-427-9628
Mailing Address - Fax:
Practice Address - Street 1:3600 LIND AVE SW
Practice Address - Street 2:SUITE 160
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-4934
Practice Address - Country:US
Practice Address - Phone:425-656-4215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003505235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist