Healthcare Provider Details

I. General information

NPI: 1295494235
Provider Name (Legal Business Name): NICOLE CARRAHER PSYD, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE CARRAHER RUSSELL

II. Dates (important events)

Enumeration Date: 12/16/2021
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 MACK ST
GASTON SC
29053-8981
US

IV. Provider business mailing address

1441 MACK ST
GASTON SC
29053-8981
US

V. Phone/Fax

Practice location:
  • Phone: 980-274-7192
  • Fax:
Mailing address:
  • Phone: 980-274-7192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPLSW5511
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: