Provider Demographics
NPI:1740471226
Name:DEAVER, NICOLE (LPC, LMHC)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:DEAVER
Suffix:
Gender:F
Credentials:LPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 INLAND SEAS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-2504
Mailing Address - Country:US
Mailing Address - Phone:828-545-0699
Mailing Address - Fax:828-333-4320
Practice Address - Street 1:33 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-3124
Practice Address - Country:US
Practice Address - Phone:828-545-0699
Practice Address - Fax:828-333-4320
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8368101Y00000X
FLMH14265101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6104869Medicaid