Healthcare Provider Details

I. General information

NPI: 1851816193
Provider Name (Legal Business Name): NICOLE AYSSA LOLLIS LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE AYSSA HERNANDEZ LCMHC

II. Dates (important events)

Enumeration Date: 08/08/2017
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 KERNERSVILLE MEDICAL PKWY STE 101
KERNERSVILLE NC
27284-7198
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-564-4950
  • Fax: 336-564-4959
Mailing address:
  • Phone: 336-564-4950
  • Fax: 336-564-4959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13006
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: