Healthcare Provider Details

I. General information

NPI: 1275877458
Provider Name (Legal Business Name): NICOLE MARIE WAITE LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2012
Last Update Date: 11/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1318 RAEFORD RD
FAYETTEVILLE NC
28305-5482
US

IV. Provider business mailing address

5709 IVANHOE CT APT 3
FAYETTEVILLE NC
28314-4448
US

V. Phone/Fax

Practice location:
  • Phone: 859-466-7100
  • Fax:
Mailing address:
  • Phone: 859-466-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1335
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: