Healthcare Provider Details

I. General information

NPI: 1003711219
Provider Name (Legal Business Name): ELISSA RUMER NICKOLOPOULOS MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 N ROXBORO ST FL 2
DURHAM NC
27704-1826
US

IV. Provider business mailing address

4220 N ROXBORO ST FL 2
DURHAM NC
27704-1826
US

V. Phone/Fax

Practice location:
  • Phone: 919-684-1439
  • Fax: 919-477-5435
Mailing address:
  • Phone: 919-684-1439
  • Fax: 919-477-5435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC014196
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: