Provider Demographics
NPI:1104560028
Name:THE SELF-INCLUSIVE COLLECTIVE, PLLC
Entity type:Organization
Organization Name:THE SELF-INCLUSIVE COLLECTIVE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER, LICENSED COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MIMS
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, LPC
Authorized Official - Phone:571-268-1466
Mailing Address - Street 1:100 N HOWARD ST STE 4424
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-0508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4018 CALIFORNIA AVE SW APT 5
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-3782
Practice Address - Country:US
Practice Address - Phone:206-569-4509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-26
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty