Provider Demographics
NPI:1699548461
Name:RADCLIFF, NICOLE ANN
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ANN
Last Name:RADCLIFF
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:ANN
Other - Last Name:TEFFT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NICOLE FENDER
Mailing Address - Street 1:759 JIM GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:SNEADS FERRY
Mailing Address - State:NC
Mailing Address - Zip Code:28460-6793
Mailing Address - Country:US
Mailing Address - Phone:334-805-6144
Mailing Address - Fax:
Practice Address - Street 1:10 DEWITT ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-5649
Practice Address - Country:US
Practice Address - Phone:334-805-6144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-03
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA19238101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health