Provider Demographics
NPI:1427694686
Name:NICHOLLS, SUSAN LYNN (SUDPT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:NICHOLLS
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5729 156TH ST SW
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-4617
Mailing Address - Country:US
Mailing Address - Phone:206-612-3852
Mailing Address - Fax:
Practice Address - Street 1:11627 AIRPORT RD STE B
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-8714
Practice Address - Country:US
Practice Address - Phone:425-248-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)