Provider Demographics
NPI:1639579931
Name:NICKELSEN, PEGGY Y (LMHC)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:Y
Last Name:NICKELSEN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17852
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32522-7852
Mailing Address - Country:US
Mailing Address - Phone:850-346-2922
Mailing Address - Fax:
Practice Address - Street 1:901 W MORENO ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-2314
Practice Address - Country:US
Practice Address - Phone:850-637-1429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10478101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH 10478OtherLICENSE