Provider Demographics
NPI:1700411931
Name:TAI, NICOLE (LCSWA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:TAI
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3664 GENESIS LN
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6088
Mailing Address - Country:US
Mailing Address - Phone:443-538-7275
Mailing Address - Fax:
Practice Address - Street 1:3664 GENESIS LN
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6088
Practice Address - Country:US
Practice Address - Phone:443-538-7275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0144371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical