Healthcare Provider Details

I. General information

NPI: 1497802995
Provider Name (Legal Business Name): CAROLYN J. NICHOLS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1736 E SUNSHINE ST PLAZA TOWERS-SUITE 508
SPRINGFIELD MO
65804-1343
US

IV. Provider business mailing address

4715 E BITTERSWEET WAY
SPRINGFIELD MO
65809-2403
US

V. Phone/Fax

Practice location:
  • Phone: 417-766-5432
  • Fax:
Mailing address:
  • Phone: 417-887-7803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number002622
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: