Provider Demographics
NPI:1114618873
Name:NICHOLS, CASEY MARIE
Entity Type:Individual
Prefix:MISS
First Name:CASEY
Middle Name:MARIE
Last Name:NICHOLS
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 1:3204 IMMANUEL RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-3537
Mailing Address - Country:US
Mailing Address - Phone:336-814-7399
Mailing Address - Fax:
Practice Address - Street 1:4160 PIEDMONT PKWY
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-8174
Practice Address - Country:US
Practice Address - Phone:336-645-6733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT-23-270534106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician