Provider Demographics
NPI:1639651219
Name:BASH, NICOLE VICTORIA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:VICTORIA
Last Name:BASH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 112TH ST SW APT A103
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-7814
Mailing Address - Country:US
Mailing Address - Phone:425-499-5947
Mailing Address - Fax:
Practice Address - Street 1:8848 NE 116TH PL
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-6113
Practice Address - Country:US
Practice Address - Phone:425-394-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician