Healthcare Provider Details

I. General information

NPI: 1962878587
Provider Name (Legal Business Name): NICOLE ENSLOW HSP, SUDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2015
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14090 FRYELANDS BLVD SE STE 347
MONROE WA
98272-2760
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 360-805-3122
  • Fax:
Mailing address:
  • Phone: 206-764-0502
  • Fax: 206-764-0516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number60553755
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP61004872
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: