Healthcare Provider Details

I. General information

NPI: 1083879167
Provider Name (Legal Business Name): CARRIE A NICKLES LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2008
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N 48TH ST
SPRINGDALE AR
72762-3743
US

IV. Provider business mailing address

3960 W OWL CREEK PL
FAYETTEVILLE AR
72704-6237
US

V. Phone/Fax

Practice location:
  • Phone: 303-905-9025
  • Fax: 479-358-1493
Mailing address:
  • Phone: 303-905-9025
  • Fax: 479-358-1493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP1108056
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: