Provider Demographics
NPI:1225442817
Name:MEDEIROS, NICOLLE ADELE (BS)
Entity Type:Individual
Prefix:MS
First Name:NICOLLE
Middle Name:ADELE
Last Name:MEDEIROS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 N STERLING BLVD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-2322
Mailing Address - Country:US
Mailing Address - Phone:703-439-4279
Mailing Address - Fax:
Practice Address - Street 1:11240 WAPLES MILL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6078
Practice Address - Country:US
Practice Address - Phone:703-237-2219
Practice Address - Fax:703-237-2729
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program