Provider Demographics
NPI:1992399281
Name:FORTUNE, NICOLE C (MSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:C
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7660 SUMTER CREST DR APT 6001
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-6803
Mailing Address - Country:US
Mailing Address - Phone:843-377-9264
Mailing Address - Fax:
Practice Address - Street 1:10520 LITTLE BRIER CREEK LN # 205
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-2012
Practice Address - Country:US
Practice Address - Phone:984-244-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP013231101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty