Provider Demographics
NPI:1336417716
Name:SHOCKMAN, NICHOLAS (PSYD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:SHOCKMAN
Suffix:
Gender:M
Credentials:PSYD
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 5054
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99302-5054
Mailing Address - Country:US
Mailing Address - Phone:804-972-6816
Mailing Address - Fax:
Practice Address - Street 1:3311 W CLEARWATER AVE
Practice Address - Street 2:SUITE C-200D
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-2710
Practice Address - Country:US
Practice Address - Phone:509-491-8191
Practice Address - Fax:509-396-7556
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WA60315203103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor