Healthcare Provider Details

I. General information

NPI: 1467098632
Provider Name (Legal Business Name): ADRIANA CRISTINA GOMEZ-NICHOLS LCMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2019
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 W DURHAM ST
KILL DEVIL HILLS NC
27948-8276
US

IV. Provider business mailing address

703 W DURHAM ST
KILL DEVIL HILLS NC
27948-8276
US

V. Phone/Fax

Practice location:
  • Phone: 919-297-8175
  • Fax:
Mailing address:
  • Phone: 919-297-8175
  • Fax: 252-417-7982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number15118
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15118
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: