Healthcare Provider Details

I. General information

NPI: 1386859429
Provider Name (Legal Business Name): NICOLLE ANDERSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 J N PEASE PL SUITE 104
CHARLOTTE NC
28262-4557
US

IV. Provider business mailing address

8728 ARBOR COMMOMS LN
CONCORD NC
28027-3575
US

V. Phone/Fax

Practice location:
  • Phone: 704-599-4679
  • Fax:
Mailing address:
  • Phone: 704-795-9150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number102528
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: