Provider Demographics
NPI:1386859429
Name:ANDERSON, NICOLLE (PHD)
Entity type:Individual
Prefix:
First Name:NICOLLE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8728 ARBOR COMMOMS LN
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-3575
Mailing Address - Country:US
Mailing Address - Phone:704-795-9150
Mailing Address - Fax:
Practice Address - Street 1:1905 J N PEASE PL
Practice Address - Street 2:SUITE 104
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4557
Practice Address - Country:US
Practice Address - Phone:704-599-4679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102528103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent