Provider Demographics
NPI:1689319261
Name:NICHOLSON, KIM (LCPC, NCC, CCTP, PMP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:LCPC, NCC, CCTP, PMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-1634 ULAULA LOOP
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-6858
Mailing Address - Country:US
Mailing Address - Phone:301-742-1185
Mailing Address - Fax:
Practice Address - Street 1:91-1634 ULAULA LOOP
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-6858
Practice Address - Country:US
Practice Address - Phone:301-742-1185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-28
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC12633101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLC12633OtherBOARD OF PROFESSIONAL COUNSELORS&THERAPISTS