Provider Demographics
NPI:1578339990
Name:DEL RISCO, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DEL RISCO
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 1:6900 ROSWELL RD APT H5
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328-2213
Mailing Address - Country:US
Mailing Address - Phone:706-714-3856
Mailing Address - Fax:
Practice Address - Street 1:1539 OLD VALDOSTA RD
Practice Address - Street 2:
Practice Address - City:RAY CITY
Practice Address - State:GA
Practice Address - Zip Code:31645-7132
Practice Address - Country:US
Practice Address - Phone:706-714-3856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003611101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health