Provider Demographics
NPI:1467856559
Name:TANK, NICOLE M (MA)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:M
Last Name:TANK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:NUITRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:124 MALLARD ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-4046
Mailing Address - Country:US
Mailing Address - Phone:864-241-1040
Mailing Address - Fax:864-241-8189
Practice Address - Street 1:124 MALLARD ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-4046
Practice Address - Country:US
Practice Address - Phone:864-241-1040
Practice Address - Fax:864-241-8189
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301100Medicaid
SC3333Medicare PIN