Healthcare Provider Details

I. General information

NPI: 1053781062
Provider Name (Legal Business Name): NICOLE NICHOLS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2015
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34465 AMBROSE HOOVER RD
TICKFAW LA
70466-3917
US

IV. Provider business mailing address

PO BOX 2008
ALBANY LA
70711-8008
US

V. Phone/Fax

Practice location:
  • Phone: 985-351-9643
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5174
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: