Provider Demographics
NPI:1922637982
Name:NICKELSON, CAROL WILLIAMS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:WILLIAMS
Last Name:NICKELSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:21385 GLEBE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:BROADLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:20148-3629
Mailing Address - Country:US
Mailing Address - Phone:703-723-0119
Mailing Address - Fax:
Practice Address - Street 1:20925 PROFESSIONAL PLZ STE 230
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-3403
Practice Address - Country:US
Practice Address - Phone:703-621-7121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2020-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
VA0810007253103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist