Provider Demographics
NPI:1124623541
Name:SPANN, NICOLE M
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:SPANN
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 1:1776 BURNING TREE RD.
Mailing Address - Street 2:#312
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210
Mailing Address - Country:US
Mailing Address - Phone:803-319-1780
Mailing Address - Fax:
Practice Address - Street 1:1776 BURNING TREE RD.
Practice Address - Street 2:#312
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210
Practice Address - Country:US
Practice Address - Phone:803-319-1780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician