Provider Demographics
NPI:1851816193
Name:LOLLIS, NICOLE AYSSA (LCMHC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:AYSSA
Last Name:LOLLIS
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:AYSSA
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCMHC
Mailing Address - Street 1:8025 N POINT BLVD STE 141
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3753
Mailing Address - Country:US
Mailing Address - Phone:336-546-5003
Mailing Address - Fax:
Practice Address - Street 1:450 W HANES MILL RD STE 224
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-7404
Practice Address - Country:US
Practice Address - Phone:336-546-5003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2023-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13006101YM0800X
NC13006101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health