Provider Demographics
NPI:1538389291
Name:GAUSE, NICHELLE (LPC, NCC)
Entity type:Individual
Prefix:
First Name:NICHELLE
Middle Name:
Last Name:GAUSE
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:286 MONARCH VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7766
Mailing Address - Country:US
Mailing Address - Phone:678-289-4394
Mailing Address - Fax:
Practice Address - Street 1:110 EAGLES WALK STE 100
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7203
Practice Address - Country:US
Practice Address - Phone:770-507-6044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005157101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional