Healthcare Provider Details

I. General information

NPI: 1265210009
Provider Name (Legal Business Name): NICOLE SHAH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2023
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 MARKET ST STE 205
FORT MILL SC
29708-6529
US

IV. Provider business mailing address

951 MARKET ST STE 205
FORT MILL SC
29708-6529
US

V. Phone/Fax

Practice location:
  • Phone: 803-372-8585
  • Fax: 800-598-6601
Mailing address:
  • Phone: 803-372-8585
  • Fax: 800-598-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8486
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: