Provider Demographics
NPI:1710071428
Name:NICHOLAIDES, ELIZABETH (LCSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:NICHOLAIDES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4708 BLACK MOUNTAIN PATH
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612
Mailing Address - Country:US
Mailing Address - Phone:919-845-9977
Mailing Address - Fax:919-845-9761
Practice Address - Street 1:312 W. MILLBROOK ROAD
Practice Address - Street 2:SUITE 109
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609
Practice Address - Country:US
Practice Address - Phone:919-845-9977
Practice Address - Fax:919-845-9761
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC004918104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003272Medicaid