Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP1600X | Pastoral Counselor | 11102014 | GA |
NPI | 1255724704 |
---|---|
Provider Name | Tracy Nichols |
First Address | Douglasville, GA 30134-4066 |
Second Address | Douglasville, GA 30134-4066 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2015 |
Last Update Date | 15/07/2020 |