Provider Demographics
NPI:1508268764
Name:GAINES, NICOLE LAUREN (LPC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LAUREN
Last Name:GAINES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LAUREN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1760 WORTMAN ST
Mailing Address - Street 2:
Mailing Address - City:CONNELLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28612-8073
Mailing Address - Country:US
Mailing Address - Phone:828-315-1782
Mailing Address - Fax:
Practice Address - Street 1:1760 WORTMAN ST
Practice Address - Street 2:
Practice Address - City:CONNELLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28612-8073
Practice Address - Country:US
Practice Address - Phone:828-315-1782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9896101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional