Healthcare Provider Details

I. General information

NPI: 1982172086
Provider Name (Legal Business Name): NICHOLAS BLAINE NOMURA LAUDERDALE MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 07/26/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1538 E B ST
DEER PARK WA
99006-5609
US

IV. Provider business mailing address

1538 E B ST
DEER PARK WA
99006-5609
US

V. Phone/Fax

Practice location:
  • Phone: 509-638-8478
  • Fax: 509-606-3013
Mailing address:
  • Phone: 509-714-3067
  • Fax: 509-606-3013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH61295887
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: