Healthcare Provider Details

I. General information

NPI: 1750770335
Provider Name (Legal Business Name): NILE SEDGWICK LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2015
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 FOUNDERS BLVD STE B
ATHENS GA
30606-6163
US

IV. Provider business mailing address

1090 FOUNDERS BLVD STE B
ATHENS GA
30606-6163
US

V. Phone/Fax

Practice location:
  • Phone: 912-660-6407
  • Fax: 866-424-5160
Mailing address:
  • Phone: 912-660-6407
  • Fax: 866-424-5160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: