Provider Demographics
NPI:1326704974
Name:PARKES, NICOLE THERON
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:THERON
Last Name:PARKES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 WILLIAM WAY
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-8601
Mailing Address - Country:US
Mailing Address - Phone:617-631-4494
Mailing Address - Fax:
Practice Address - Street 1:5631 S PECOS RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-1961
Practice Address - Country:US
Practice Address - Phone:702-685-0877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810006375103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical