Provider Demographics
NPI:1194189944
Name:BEADLES, NICOLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:BEADLES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1517 INLET CT
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-4422
Mailing Address - Country:US
Mailing Address - Phone:571-354-0844
Mailing Address - Fax:
Practice Address - Street 1:3925 BLENHEIM BLVD STE 52A
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2426
Practice Address - Country:US
Practice Address - Phone:571-354-0844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003878103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist