Healthcare Provider Details

I. General information

NPI: 1407767114
Provider Name (Legal Business Name): MRS. ANDREA E. NICHOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 E POPLAR ST # GA
GRIFFIN GA
30224-3402
US

IV. Provider business mailing address

415 E POPLAR ST # GA
GRIFFIN GA
30224-3402
US

V. Phone/Fax

Practice location:
  • Phone: 678-208-8423
  • Fax: --
Mailing address:
  • Phone: 678-208-8423
  • Fax: --

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: