Provider Demographics
NPI:1821624438
Name:PRENTICE, NICOLE (LSWAIC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PRENTICE
Suffix:
Gender:F
Credentials:LSWAIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2848 ROAD 14.1 NW
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:WA
Mailing Address - Zip Code:98823-7822
Mailing Address - Country:US
Mailing Address - Phone:509-750-0304
Mailing Address - Fax:
Practice Address - Street 1:1021 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-2604
Practice Address - Country:US
Practice Address - Phone:509-750-0304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-14
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC610349691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical