Provider Demographics
NPI:1396235909
Name:IZATT, NICOLE LYNN
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:IZATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LYNN
Other - Last Name:PITTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:595 SHOSHONE ST
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81504-5682
Mailing Address - Country:US
Mailing Address - Phone:970-712-8074
Mailing Address - Fax:
Practice Address - Street 1:595 SHOSHONE ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81504-5682
Practice Address - Country:US
Practice Address - Phone:970-712-8074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty