Provider Demographics
NPI:1912365883
Name:VANEGAS, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:VANEGAS
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 1:117 BENNETT STREET
Mailing Address - Street 2:APT C
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:751 EAST GEORGIA ROAD
Practice Address - Street 2:STE 100
Practice Address - City:WOODRUFF
Practice Address - State:SC
Practice Address - Zip Code:29388
Practice Address - Country:US
Practice Address - Phone:803-210-7302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst