Provider Demographics
NPI:1578992947
Name:FISCHER, NICOLE (MA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FISCHER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 132
Mailing Address - Street 2:
Mailing Address - City:OLALLA
Mailing Address - State:WA
Mailing Address - Zip Code:98359
Mailing Address - Country:US
Mailing Address - Phone:360-443-0125
Mailing Address - Fax:
Practice Address - Street 1:2507 SE MILE HILL DR STE C-103
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3515
Practice Address - Country:US
Practice Address - Phone:360-443-0125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60419487101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health