Healthcare Provider Details

I. General information

NPI: 1598823072
Provider Name (Legal Business Name): DAVID LEROY NICHOLSON-KLINGERMAN SR. MA LPC, LMHC, CMHS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DAVID LEROY KLINGERMAN

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 PACIFIC AVE N
LONG BEACH WA
98631-3300
US

IV. Provider business mailing address

2204 PACIFIC AVE N
LONG BEACH WA
98631-3300
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-3787
  • Fax: 360-642-2096
Mailing address:
  • Phone: 360-642-3787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60571247
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC3354
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: