Provider Demographics
NPI:1316238660
Name:NUCKOLLS, MICHAEL W (NCC, LPC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:NUCKOLLS
Suffix:
Gender:M
Credentials:NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 BETHESDA PL
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3331
Mailing Address - Country:US
Mailing Address - Phone:336-745-5087
Mailing Address - Fax:
Practice Address - Street 1:3000 BETHESDA PL
Practice Address - Street 2:SUITE 301
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3331
Practice Address - Country:US
Practice Address - Phone:336-745-5087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2016-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8354101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional