Healthcare Provider Details

I. General information

NPI: 1376870667
Provider Name (Legal Business Name): NICOLE RENEE FORDE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2009
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2633 WEST BLVD
CHARLOTTE NC
28208-6705
US

IV. Provider business mailing address

3520 EASTOVER RIDGE DR APT. 1104
CHARLOTTE NC
28211-1576
US

V. Phone/Fax

Practice location:
  • Phone: 704-521-4977
  • Fax:
Mailing address:
  • Phone: 917-710-8594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW9299
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC008252
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: