Provider Demographics
NPI:1558533968
Name:CANTLEY, NICOLE LACOSTE (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LACOSTE
Last Name:CANTLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:LACOSTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 SARDIS RD N
Mailing Address - Street 2:SUITE 220
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227
Mailing Address - Country:US
Mailing Address - Phone:704-841-1163
Mailing Address - Fax:704-841-1164
Practice Address - Street 1:2101 SARDIS RD N
Practice Address - Street 2:SUITE 220
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227
Practice Address - Country:US
Practice Address - Phone:704-841-1163
Practice Address - Fax:704-841-1164
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3520103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical