Provider Demographics
NPI:1700597234
Name:OUTLAW, NICOLE LYNN (LAC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:OUTLAW
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6117 N 12TH ST UNIT 7
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-1718
Mailing Address - Country:US
Mailing Address - Phone:928-900-3008
Mailing Address - Fax:
Practice Address - Street 1:17505 N 79TH AVE STE 311G
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8730
Practice Address - Country:US
Practice Address - Phone:623-876-2029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-21448101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health