Provider Demographics
NPI:1407231624
Name:NICHOLS, VIVIAN (BS, MS, SSP)
Entity Type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:BS, MS, SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 HEDGEROW TRL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7269
Mailing Address - Country:US
Mailing Address - Phone:678-372-5094
Mailing Address - Fax:
Practice Address - Street 1:170 HEDGEROW TRL
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7269
Practice Address - Country:US
Practice Address - Phone:678-372-5094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007332101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional