Provider Demographics
NPI:1730507260
Name:DIBACCO, NICOLE (MA, LMHCA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DIBACCO
Suffix:
Gender:F
Credentials:MA, LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 1ST AVE
Mailing Address - Street 2:SUITE 315
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 1ST AVE
Practice Address - Street 2:SUITE 315
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2216
Practice Address - Country:US
Practice Address - Phone:206-406-2115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC 60369582101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAR51033006OtherBLUE SHIELD FEDERAL