Provider Demographics
NPI:1790296788
Name:NICHOLS, GINA GINETTE (LPCC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:GINETTE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1712 HIGHWAY 121 BYP N STE I
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-8864
Mailing Address - Country:US
Mailing Address - Phone:270-761-5804
Mailing Address - Fax:270-761-5807
Practice Address - Street 1:1712 HIGHWAY 121 BYP N STE I
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-8864
Practice Address - Country:US
Practice Address - Phone:270-761-5804
Practice Address - Fax:270-761-5807
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY103574101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional