Provider Demographics
NPI:1942600556
Name:MESA TYREE, NICHOLE (LMHC)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:MESA TYREE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:
Other - Last Name:TYREE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:52 FAIRVIEW ST EXT APT 1
Mailing Address - Street 2:
Mailing Address - City:SOUTH GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12803-4887
Mailing Address - Country:US
Mailing Address - Phone:518-791-2219
Mailing Address - Fax:
Practice Address - Street 1:52 FAIRVIEW ST EXT APT 1
Practice Address - Street 2:
Practice Address - City:SOUTH GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12803-4887
Practice Address - Country:US
Practice Address - Phone:518-791-2219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-02
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11175101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health