Provider Demographics
NPI:1104575042
Name:NICKERSON, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 N SWING RD APT 312
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27409-1909
Mailing Address - Country:US
Mailing Address - Phone:781-234-8099
Mailing Address - Fax:
Practice Address - Street 1:4160 PIEDMONT PKWY
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-8174
Practice Address - Country:US
Practice Address - Phone:336-645-6733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-19
Last Update Date:2022-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT-22-198488106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician