Provider Demographics
NPI:1427744556
Name:RUTAN, NICOLETTE CORELLA MOORE (LSWAIC)
Entity type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:CORELLA MOORE
Last Name:RUTAN
Suffix:
Gender:F
Credentials:LSWAIC
Other - Prefix:
Other - First Name:NICOLETTE
Other - Middle Name:CORELLA
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSWAIC
Mailing Address - Street 1:80 159TH PL NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008-4415
Mailing Address - Country:US
Mailing Address - Phone:281-620-9640
Mailing Address - Fax:
Practice Address - Street 1:80 159TH PL NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98008-4415
Practice Address - Country:US
Practice Address - Phone:281-620-9640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC612802351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical