Provider Demographics
NPI:1073265989
Name:STACK, NICOLE VICTORIA ASHA
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:VICTORIA ASHA
Last Name:STACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:VICTORIA ASHA
Other - Last Name:KILLION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 E PIONEER
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3265
Mailing Address - Country:US
Mailing Address - Phone:253-697-8400
Mailing Address - Fax:
Practice Address - Street 1:325 E PIONEER
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3265
Practice Address - Country:US
Practice Address - Phone:253-697-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61247305101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor