MEDICARE: WILBERT NICHOLS III LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	9670	NC

General Provider Information

NPI Number	:	1447685508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILBERT NICHOLS III LPC

Provider Business Mailing Address
First Line	:	PO BOX 87195
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28304-0000
Country	:	US
Telephone Number	:	910-486-8989
Fax Number	:	910-826-3695

Provider Business Practice Location Address
First Line	:	2905 BREEZEWOOD AVE
Second Line	:	SUITE 104
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28303-5503
Country	:	US
Telephone Number	:	910-486-8989
Fax Number	:	910-826-3695

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2013
Last Update Date	:	02/22/2016

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