Provider Demographics
NPI:1184808701
Name:NICHOLSON, MIKE LYLE (BS)
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:LYLE
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 CORNWALL AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4642
Mailing Address - Country:US
Mailing Address - Phone:360-676-6177
Mailing Address - Fax:
Practice Address - Street 1:1616 CORNWALL AVE STE 205
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225
Practice Address - Country:US
Practice Address - Phone:360-676-6177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW60717124101Y00000X, 104100000X, 1041C0700X
WARC00055096302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No302R00000XManaged Care OrganizationsHealth Maintenance Organization