Provider Demographics
NPI:1720550486
Name:TANNHEIMER, NICOLE JACQUELINE (BFA, CDP, NCAC I)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JACQUELINE
Last Name:TANNHEIMER
Suffix:
Gender:F
Credentials:BFA, CDP, NCAC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SW 7TH STE. B
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057
Mailing Address - Country:US
Mailing Address - Phone:206-248-4358
Mailing Address - Fax:425-430-9770
Practice Address - Street 1:1000 SW 7TH ST STE B
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-5216
Practice Address - Country:US
Practice Address - Phone:206-248-4358
Practice Address - Fax:425-430-9770
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00005781101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACD00005781OtherLAKESIDE MILAM RECOVERY CENTERS
WA101YA400XOtherLAKESIDE MILAM RECOVERY CENTERS