MEDICARE: DR. ANASTACIA A. NICHOLS PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY004308	GA

General Provider Information

NPI Number	:	1174185763
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANASTACIA A. NICHOLS PSYD

Provider Business Mailing Address
First Line	:	1441 CLIFTON RD NE STE 170
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30322-1004
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 EXECUTIVE PARK DR NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30329-2206
Country	:	US
Telephone Number	:	404-712-5667
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2019
Last Update Date	:	01/20/2026

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