Provider Demographics
NPI:1063661494
Name:WHITE, NICOLE LEIGH
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEIGH
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 SOMERVILLE RD SE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-4305
Mailing Address - Country:US
Mailing Address - Phone:256-355-6105
Mailing Address - Fax:
Practice Address - Street 1:1307 E ELM ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-5318
Practice Address - Country:US
Practice Address - Phone:256-355-6105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2934101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health