MEDICARE: NICOLE PEDERSON

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1275049900
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE PEDERSON

Provider Business Mailing Address
First Line	:	445 MARKHAM ST SW APT D2
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30313-1405
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	215 LAKEWOOD WAY SW # 205
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30315-6022
Country	:	US
Telephone Number	:	678-335-9010
Fax Number	:

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

Provider Enumeration Date	:	12/18/2017
Last Update Date	:	12/18/2017

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Directions to “ NICOLE PEDERSON ” Practice Location

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