Healthcare Provider Details

I. General information

NPI: 1972032449
Provider Name (Legal Business Name): NACOLE MARIETTA HOLMES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 NE 129TH ST STE 101
VANCOUVER WA
98686-3270
US

IV. Provider business mailing address

954 CASCADE DR
LONGVIEW WA
98632-5618
US

V. Phone/Fax

Practice location:
  • Phone: 360-574-9303
  • Fax: 360-574-9311
Mailing address:
  • Phone: 360-513-7304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLW61544692
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLW61544692
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW61544692
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: