Provider Demographics
NPI:1851034052
Name:CHAFIN, NICOLETTE
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:CHAFIN
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 1:6071 QUEENS RIVER DR
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-3696
Mailing Address - Country:US
Mailing Address - Phone:678-492-2943
Mailing Address - Fax:
Practice Address - Street 1:833 HURRICANE SHOALS RD NE
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-4821
Practice Address - Country:US
Practice Address - Phone:904-525-3637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-15
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-21-193637106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician