Basic Information
| Provider Information | |||||||||
| NPI: | 1851040927 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMMONS | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COPELAND | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2553 LOVEJOY DR | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995084132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073014201 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17025 SNOWMOBILE LN | ||||||||
| Address2: | |||||||||
| City: | EAGLE RIVER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995777044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9076967466 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2022 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | AK | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.