Provider Demographics
NPI:1194240309
Name:LIND, NICOLE KELLY
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:KELLY
Last Name:LIND
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:PO BOX 762
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98041-0762
Mailing Address - Country:US
Mailing Address - Phone:206-915-4117
Mailing Address - Fax:
Practice Address - Street 1:4526 FEDERAL AVE BLDG 1
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2132
Practice Address - Country:US
Practice Address - Phone:206-915-4117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health