Provider Demographics
NPI:1710473061
Name:OSTI, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:OSTI
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 1:3763 CAMBRIDGE DR SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1640
Mailing Address - Country:US
Mailing Address - Phone:908-432-5562
Mailing Address - Fax:
Practice Address - Street 1:995 ROSWELL ST NE STE 100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-2186
Practice Address - Country:US
Practice Address - Phone:908-432-5562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW007463101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health