Provider Demographics
NPI:1124748835
Name:NICHOLSON, RAQUEL RENEE (LCAS-A)
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:RENEE
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4641 BOYDS RD
Mailing Address - Street 2:
Mailing Address - City:GRIMESLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27837-8930
Mailing Address - Country:US
Mailing Address - Phone:252-939-0476
Mailing Address - Fax:
Practice Address - Street 1:PORT HEALTH SERVICES
Practice Address - Street 2:4300-110 SAPPHIRE COURT
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834
Practice Address - Country:US
Practice Address - Phone:252-752-0483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-28336101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)