Provider Demographics
NPI:1043587686
Name:ABBOTT, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:SMITH-VIRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 W MUHAMMAD ALI BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9702 STONESTREET RD
Practice Address - Street 2:#110
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272-6808
Practice Address - Country:US
Practice Address - Phone:502-589-8600
Practice Address - Fax:502-589-8771
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100290650Medicaid