Provider Demographics
NPI:1598281750
Name:AZAN, NICKESHA CHRISTINE
Entity Type:Individual
Prefix:
First Name:NICKESHA
Middle Name:CHRISTINE
Last Name:AZAN
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 1:400 CHURCHILL CT STE 440
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-6871
Mailing Address - Country:US
Mailing Address - Phone:202-384-2875
Mailing Address - Fax:
Practice Address - Street 1:400 CHURCHILL CT STE 440
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-6871
Practice Address - Country:US
Practice Address - Phone:202-384-2875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-19
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83024101YM0800X
390200000X
GACSW0090761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program