Provider Demographics
NPI:1760617237
Name:CEO, NIKI G (MA,LPC)
Entity Type:Individual
Prefix:
First Name:NIKI
Middle Name:G
Last Name:CEO
Suffix:
Gender:F
Credentials:MA,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899C HARRISON ST SE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175-4522
Mailing Address - Country:US
Mailing Address - Phone:703-777-4788
Mailing Address - Fax:703-777-4788
Practice Address - Street 1:899C HARRISON ST SE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-4522
Practice Address - Country:US
Practice Address - Phone:703-777-4788
Practice Address - Fax:703-777-4788
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701001190101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional