Provider Demographics
NPI:1598840639
Name:NICKLES, SHARAY A (LMHC)
Entity Type:Individual
Prefix:
First Name:SHARAY
Middle Name:A
Last Name:NICKLES
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3421
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98063-3421
Mailing Address - Country:US
Mailing Address - Phone:253-324-8521
Mailing Address - Fax:
Practice Address - Street 1:18404 97TH STREET COURT KP N
Practice Address - Street 2:
Practice Address - City:VAUGHN
Practice Address - State:WA
Practice Address - Zip Code:98394-9735
Practice Address - Country:US
Practice Address - Phone:253-324-8521
Practice Address - Fax:253-649-0025
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00010044101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1093730Medicaid
TX00G981OtherBCBSTX GRP PIN
1336198894OtherGRP NPI NUMBER
TX180195302Medicaid
TX5717290OtherFIRSTHELATH PIN
TX84944LOtherBCBSTX IND PIN
TX10054174OtherAMERIGROUP PIN