Provider Demographics
NPI:1255675146
Name:FORMWALT, NICOLE R (LPC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:FORMWALT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 GLENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36606-1905
Mailing Address - Country:US
Mailing Address - Phone:251-476-7148
Mailing Address - Fax:
Practice Address - Street 1:7305 COTTAGE HILL RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-2829
Practice Address - Country:US
Practice Address - Phone:251-422-2043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2227101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional