Provider Demographics
NPI:1194328856
Name:SURLA, NICOLE (BCABA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SURLA
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3119 RENAISSANCE WAY NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2463
Mailing Address - Country:US
Mailing Address - Phone:912-223-8200
Mailing Address - Fax:
Practice Address - Street 1:1780 OAK RD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2202
Practice Address - Country:US
Practice Address - Phone:678-691-6797
Practice Address - Fax:678-302-3453
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0-20-11349103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst