Provider Demographics
NPI:1528812716
Name:NICHOLSON, DUSTIN R
Entity type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:R
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N HOWARD ST STE W
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-0508
Mailing Address - Country:US
Mailing Address - Phone:253-315-0581
Mailing Address - Fax:
Practice Address - Street 1:100 N HOWARD ST STE W
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-0508
Practice Address - Country:US
Practice Address - Phone:253-315-0581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61530475101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health