Provider Demographics
NPI:1154656023
Name:DAVIS, NICOLE PATRICH (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:PATRICH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 LIBERTY HTS
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-4413
Mailing Address - Country:US
Mailing Address - Phone:404-645-6551
Mailing Address - Fax:404-923-9932
Practice Address - Street 1:1862 PRINCETON AVE # 206
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30337-3519
Practice Address - Country:US
Practice Address - Phone:404-645-6551
Practice Address - Fax:404-923-9932
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-12
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC001781101YP2500X
GALPC006241101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003133311AMedicaid