Healthcare Provider Details

I. General information

NPI: 1033667944
Provider Name (Legal Business Name): DAX JOSEPH NICOLA MA, CDP, MAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 THOMPSON DR
SEDRO WOOLLEY WA
98284-5007
US

IV. Provider business mailing address

1960 THOMPSON DR
SEDRO WOOLLEY WA
98284-5007
US

V. Phone/Fax

Practice location:
  • Phone: 360-856-3186
  • Fax:
Mailing address:
  • Phone: 360-856-3186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP00004631
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberMAC502067
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: