Provider Demographics
NPI:1811642366
Name:NICKELS, BRANDY
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:NICKELS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 GRADY WINKLER RD
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-8579
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:709 NORTHEAST DR STE 22
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-7425
Practice Address - Country:US
Practice Address - Phone:336-209-2884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12380A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist