Provider Demographics
NPI:1467037689
Name:NICHOLS COUNSELING SERVICES LLC
Entity type:Organization
Organization Name:NICHOLS COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-886-0999
Mailing Address - Street 1:5300 BRICKLEBERRY WAY STE 206
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-4068
Mailing Address - Country:US
Mailing Address - Phone:678-886-0999
Mailing Address - Fax:770-485-1821
Practice Address - Street 1:5300 BRICKLEBERRY WAY STE 206
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-4068
Practice Address - Country:US
Practice Address - Phone:678-886-0999
Practice Address - Fax:770-485-1821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003239367AMedicaid