Provider Demographics
NPI:1962991513
Name:GRIMES, NICHOLE (MA, LPC, LMHC)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:GRIMES
Suffix:
Gender:F
Credentials:MA, LPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 MANSELL RD STE A205
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-5019
Mailing Address - Country:US
Mailing Address - Phone:678-756-2232
Mailing Address - Fax:
Practice Address - Street 1:1007 MANSELL RD STE A205
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5019
Practice Address - Country:US
Practice Address - Phone:678-756-2232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012800101YP2500X, 101Y00000X
FLMH13235101Y00000X
AL3676101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional