Provider Demographics
NPI:1598823072
Name:NICHOLSON-KLINGERMAN, DAVID LEROY SR (MA LPC, LMHC, CMHS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEROY
Last Name:NICHOLSON-KLINGERMAN
Suffix:SR
Gender:M
Credentials:MA LPC, LMHC, CMHS
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:LEROY
Other - Last Name:KLINGERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2204 PACIFIC AVE N
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:WA
Mailing Address - Zip Code:98631-3300
Mailing Address - Country:US
Mailing Address - Phone:360-642-3787
Mailing Address - Fax:
Practice Address - Street 1:2204 PACIFIC AVE N
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:WA
Practice Address - Zip Code:98631-3300
Practice Address - Country:US
Practice Address - Phone:360-642-3787
Practice Address - Fax:360-642-2096
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60571247101YM0800X
ORC3354101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40976000Medicaid