Healthcare Provider Details

I. General information

NPI: 1770813016
Provider Name (Legal Business Name): CRYSTAL E. NICKERSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2010
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 W. MEADOWVIEW ROAD SUITE 228
GREENSBORO NC
27407-6012
US

IV. Provider business mailing address

2302 W. MEADOWVIEW ROAD SUITE 228; BOX 24
GREENSBORO NC
27407-6012
US

V. Phone/Fax

Practice location:
  • Phone: 336-218-5176
  • Fax: 336-854-0279
Mailing address:
  • Phone: 336-218-5176
  • Fax: 336-854-0279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name: MRS. CRYSTAL E NICKERSON
Title or Position: DIRECTOR
Credential:
Phone: 336-508-8190