Healthcare Provider Details

I. General information

NPI: 1225950629
Provider Name (Legal Business Name): MALLORY ELISE NICOLL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7047 LEE HWY
CHATTANOOGA TN
37421-1793
US

IV. Provider business mailing address

7047 LEE HWY
CHATTANOOGA TN
37421-1793
US

V. Phone/Fax

Practice location:
  • Phone: 615-663-1320
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: