=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659801355
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE FUGLEWICZ LAPC, NCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2017
-----------------------------------------------------
Last Update Date | 06/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 CHAMBLEE TUCKER RD BLDG 12
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30341-4100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-344-3811
-----------------------------------------------------
Fax | 770-818-5873
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 811 PENN AVE NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30308-1524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-344-3811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | APC005442
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------