Provider Demographics
NPI:1568650463
Name:NICHOLS, CANDACE RAE JEFFRIES (MS LPC)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:RAE JEFFRIES
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:RAE
Other - Last Name:JEFFRIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:1108 N WHEELER AVE
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955
Mailing Address - Country:US
Mailing Address - Phone:918-775-5513
Mailing Address - Fax:
Practice Address - Street 1:1108 N WHEELER AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-2227
Practice Address - Country:US
Practice Address - Phone:918-775-5513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4595101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional