Healthcare Provider Details

I. General information

NPI: 1619907987
Provider Name (Legal Business Name): LINDA MARIE NICOLOTTI PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910A BRIARCLIFF RD
WINSTON SALEM NC
27106-3077
US

IV. Provider business mailing address

2910A BRIARCLIFF RD
WINSTON SALEM NC
27106-3077
US

V. Phone/Fax

Practice location:
  • Phone: 336-748-9070
  • Fax: 336-773-0332
Mailing address:
  • Phone: 336-748-9070
  • Fax: 336-773-0332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2948
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: