Healthcare Provider Details

I. General information

NPI: 1649423724
Provider Name (Legal Business Name): NICOLE CARSON DEGOMEZ LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 07/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 W. UNIVERSITY #202
FLAGSTAFF AZ
86001
US

IV. Provider business mailing address

1016 W. UNIVERSITY #202
FLAGSTAFF AZ
86001
US

V. Phone/Fax

Practice location:
  • Phone: 928-773-7774
  • Fax: 928-774-1148
Mailing address:
  • Phone: 928-773-7774
  • Fax: 928-774-1148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-4026
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: