Provider Demographics
NPI:1982172086
Name:LAUDERDALE, NICHOLAS BLAINE NOMURA (MS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:BLAINE NOMURA
Last Name:LAUDERDALE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1538 E B ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006-5609
Mailing Address - Country:US
Mailing Address - Phone:509-714-3067
Mailing Address - Fax:
Practice Address - Street 1:5901 N LIDGERWOOD ST, SUITE 115
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-1510
Practice Address - Country:US
Practice Address - Phone:509-838-4651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60851735101Y00000X
WALH1295887101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor