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General NPI Number Information
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NPI Number | 1104560028
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Entity Type | Organization
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Legal Business Name | THE SELF-INCLUSIVE COLLECTIVE, PLLC
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Dates
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Enumeration Date | 04/26/2022
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Last Update Date | 04/03/2023
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Provider Practice Location Address
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Address Line | 4018 CALIFORNIA AVE SW APT 5
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City | SEATTLE
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State | WA
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Zip | 98116-3782
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Country | US
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Telephone | 206-569-4509
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Fax |
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Provider Business Mailing Address
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Address Line | 100 N HOWARD ST STE 4424
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City | SPOKANE
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State | WA
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Zip | 99201-0508
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEMBER, LICENSED COUNSELOR
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Name | NICHOLAS MIMS
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Credential | LMHC, LPC
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Telephone | 571-268-1466
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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