Provider Demographics
NPI:1285246009
Name:DOUGLAS, NICKESHA MELISA (MS)
Entity type:Individual
Prefix:
First Name:NICKESHA
Middle Name:MELISA
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 WINDY HILL RD APT 712
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-6451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1976 FLAT SHOALS RD SE STE A
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-2857
Practice Address - Country:US
Practice Address - Phone:678-856-0471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health