Basic Information
| Provider Information | |||||||||
| NPI: | 1912376559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EBERLE | ||||||||
| FirstName: | NICHOL | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GEPNER | ||||||||
| OtherFirstName: | NICHOL | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16042 143RD AVE SE | ||||||||
| Address2: | |||||||||
| City: | YELM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985979169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257601321 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3214 W MCGRAW ST | ||||||||
| Address2: | STE 212 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981993239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064534882 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2015 | ||||||||
| LastUpdateDate: | 10/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | CG60525497 | WA | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | CG60525497 | WA | Y |
No ID Information.