Healthcare Provider Details

I. General information

NPI: 1669031977
Provider Name (Legal Business Name): NICOLE MICHELLE FLYNN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 114TH AVE SE STE 224
BELLEVUE WA
98004-6905
US

IV. Provider business mailing address

1621 114TH AVE SE STE 224
BELLEVUE WA
98004-6905
US

V. Phone/Fax

Practice location:
  • Phone: 425-449-6963
  • Fax:
Mailing address:
  • Phone: 425-449-6963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW60510863
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: