Provider Demographics
NPI:1518545649
Name:HOLLER-BLACKMON, NICOLE (LPC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HOLLER-BLACKMON
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 1:9193 SWANNANOA TRL
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-3918
Mailing Address - Country:US
Mailing Address - Phone:804-477-4808
Mailing Address - Fax:
Practice Address - Street 1:9193 SWANNANOA TRL
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-3918
Practice Address - Country:US
Practice Address - Phone:804-477-4808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701009509101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health