Provider Demographics
NPI:1255724704
Name:NICHOLS, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 BRICKLEBERRY WAY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-4066
Mailing Address - Country:US
Mailing Address - Phone:678-886-0999
Mailing Address - Fax:
Practice Address - Street 1:5300 BRICKLEBERRY WAY
Practice Address - Street 2:SUITE 103
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-4066
Practice Address - Country:US
Practice Address - Phone:678-886-0999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-09
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11102014101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral