Provider Demographics
NPI:1356995518
Name:LOPEZ, NICOLE (PHD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 SW LOST TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-6002
Mailing Address - Country:US
Mailing Address - Phone:541-521-4541
Mailing Address - Fax:
Practice Address - Street 1:1550 SW LOST TRAIL DR
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-6002
Practice Address - Country:US
Practice Address - Phone:541-521-4541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA0002846Medicaid