Provider Demographics
NPI:1124750856
Name:HEATH, NICOLE MARIE (LPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:HEATH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 INDEPENDENCE BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-5569
Mailing Address - Country:US
Mailing Address - Phone:757-464-2470
Mailing Address - Fax:
Practice Address - Street 1:1209 INDEPENDENCE BLVD STE 105
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-5569
Practice Address - Country:US
Practice Address - Phone:757-494-2470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701011567101YM0800X, 103TC2200X, 101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No101Y00000XBehavioral Health & Social Service ProvidersCounselor