Healthcare Provider Details

I. General information

NPI: 1366933129
Provider Name (Legal Business Name): NICOLE M BAILEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2018
Last Update Date: 05/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 CHAMBLEE DUNWOODY RD
CHAMBLEE GA
30341-2064
US

IV. Provider business mailing address

2984 VINING RIDGE LN
DECATUR GA
30034-7504
US

V. Phone/Fax

Practice location:
  • Phone: 404-468-2274
  • Fax:
Mailing address:
  • Phone: 404-468-2274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW004816
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: