Provider Demographics
NPI:1992433643
Name:HEINO, NICHOLAS JOHN WILLIAM (SUDPT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOHN WILLIAM
Last Name:HEINO
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4841 AUTO CENTER WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-4388
Mailing Address - Country:US
Mailing Address - Phone:360-373-1529
Mailing Address - Fax:
Practice Address - Street 1:4841 AUTO CENTER WAY STE 101
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-4388
Practice Address - Country:US
Practice Address - Phone:360-373-1529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60822088101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91-1385373Medicaid