Provider Demographics
NPI:1568984946
Name:NICHOLAS, DESIREE
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 TECH CENTER DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37912-2747
Mailing Address - Country:US
Mailing Address - Phone:865-637-9711
Mailing Address - Fax:865-450-4286
Practice Address - Street 1:5310 BALL CAMP PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37921-3234
Practice Address - Country:US
Practice Address - Phone:865-539-2409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5007101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ066275Medicaid