Provider Demographics
NPI:1922353606
Name:UNDERWOOD, NICOLE SIMONE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SIMONE
Last Name:UNDERWOOD
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 1:1010 S 336TH ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6385
Mailing Address - Country:US
Mailing Address - Phone:866-835-8091
Mailing Address - Fax:
Practice Address - Street 1:1010 S 336TH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6385
Practice Address - Country:US
Practice Address - Phone:866-835-8091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60286485225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist