Provider Demographics
NPI:1083879167
Name:NICKLES, CARRIE A (LPC)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:A
Last Name:NICKLES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3960 W OWL CREEK PL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-6237
Mailing Address - Country:US
Mailing Address - Phone:303-905-9025
Mailing Address - Fax:479-358-1493
Practice Address - Street 1:801 VINEY GROVE RD
Practice Address - Street 2:
Practice Address - City:PRAIRIE GROVE
Practice Address - State:AR
Practice Address - Zip Code:72753-2623
Practice Address - Country:US
Practice Address - Phone:303-905-9025
Practice Address - Fax:479-358-1493
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-28
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1108056101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR227848719Medicaid