MEDICARE: CLAUDIA LYNN NICKOLSON

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	101YP2500X	Professional Counselor	A18612	NC

General Provider Information

NPI Number	:	1649969494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLAUDIA LYNN NICKOLSON

Provider Business Mailing Address
First Line	:	30201 E LAKE RD
Second Line	:
City	:	WAGRAM
State	:	NC
Zip	:	28396-9574
Country	:	US
Telephone Number	:	614-204-0407
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 EDINBURGH SOUTH DR STE 105
Second Line	:
City	:	CARY
State	:	NC
Zip	:	27511-6484
Country	:	US
Telephone Number	:	984-299-3377
Fax Number	:

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

Provider Enumeration Date	:	05/05/2023
Last Update Date	:	05/05/2023

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