Provider Demographics
NPI:1073023164
Name:FUENTES, NICOLE (LPC, LMHC, NCC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FUENTES
Suffix:
Gender:F
Credentials:LPC, LMHC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3228 WAKEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-5677
Mailing Address - Country:US
Mailing Address - Phone:404-313-9962
Mailing Address - Fax:
Practice Address - Street 1:5440 LAWRENCEVILLE HWY NW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-5927
Practice Address - Country:US
Practice Address - Phone:678-802-9355
Practice Address - Fax:678-802-9355
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7359101YM0800X
GALPC004808101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health