Provider Demographics
NPI:1093248866
Name:SHACKELFORD-MARTIN, NICOLETTE NARI (LPC)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:NARI
Last Name:SHACKELFORD-MARTIN
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 1:271 S CULVER ST STE D
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4805
Mailing Address - Country:US
Mailing Address - Phone:404-586-4267
Mailing Address - Fax:800-684-0723
Practice Address - Street 1:271 S CULVER ST STE D
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4805
Practice Address - Country:US
Practice Address - Phone:404-586-4267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009371101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional