Provider Demographics
NPI:1225623556
Name:NICHOLS, TARA ELIZABETH (MHC, LPC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ELIZABETH
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MHC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 AUTUMN WOODS CT
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-7342
Mailing Address - Country:US
Mailing Address - Phone:678-634-8989
Mailing Address - Fax:
Practice Address - Street 1:6130 PRESTLEY MILL RD STE A
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2288
Practice Address - Country:US
Practice Address - Phone:770-949-9675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012024101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health