Healthcare Provider Details

I. General information

NPI: 1275049900
Provider Name (Legal Business Name): NICOLE PEDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2017
Last Update Date: 12/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 LAKEWOOD WAY SW # 205
ATLANTA GA
30315-6022
US

IV. Provider business mailing address

445 MARKHAM ST SW APT D2
ATLANTA GA
30313-1405
US

V. Phone/Fax

Practice location:
  • Phone: 678-335-9010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: