Provider Demographics
NPI:1225744345
Name:NULL, NICOLE (MA/ST)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NULL
Suffix:
Gender:F
Credentials:MA/ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 GROOVER RD NE
Mailing Address - Street 2:
Mailing Address - City:LUDOWICI
Mailing Address - State:GA
Mailing Address - Zip Code:31316-4811
Mailing Address - Country:US
Mailing Address - Phone:785-477-5583
Mailing Address - Fax:
Practice Address - Street 1:1518 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-9439
Practice Address - Country:US
Practice Address - Phone:912-559-5536
Practice Address - Fax:614-388-3712
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health