Provider Demographics
NPI:1740898303
Name:OLIVARES RODRIGUEZ, NICHOLL (PPC)
Entity type:Individual
Prefix:
First Name:NICHOLL
Middle Name:
Last Name:OLIVARES RODRIGUEZ
Suffix:
Gender:F
Credentials:PPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 HI COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-9442
Mailing Address - Country:US
Mailing Address - Phone:307-699-4865
Mailing Address - Fax:
Practice Address - Street 1:140 E BROADWAY AVE # B-13
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8632
Practice Address - Country:US
Practice Address - Phone:307-413-6528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-1196101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor