Provider Demographics
NPI:1881165124
Name:SMITH, NICOLE MICHELE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELE
Last Name:SMITH
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 1:908 5TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-1507
Mailing Address - Country:US
Mailing Address - Phone:360-754-2423
Mailing Address - Fax:360-357-2819
Practice Address - Street 1:908 5TH AVE SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-1507
Practice Address - Country:US
Practice Address - Phone:360-754-2423
Practice Address - Fax:360-357-2819
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60919531101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health