Healthcare Provider Details

I. General information

NPI: 1588578702
Provider Name (Legal Business Name): NICOLE CHELONIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4112 INNSLAKE DR
GLEN ALLEN VA
23060-3344
US

IV. Provider business mailing address

4316 ARMSTRONG DR
MECHANICSVILLE VA
23111-4919
US

V. Phone/Fax

Practice location:
  • Phone: 804-495-1066
  • Fax:
Mailing address:
  • Phone: 804-495-1066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704019602
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: