Provider Demographics
NPI:1548066095
Name:NIMMO, NICOLE W (LPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:W
Last Name:NIMMO
Suffix:
Gender:
Credentials:LPC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3120 N OAK STREET EXT STE C
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-5910
Mailing Address - Country:US
Mailing Address - Phone:229-896-4559
Mailing Address - Fax:
Practice Address - Street 1:203 INDUSTRIAL PARK DR
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620-3446
Practice Address - Country:US
Practice Address - Phone:229-896-4559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-24
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC015426101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional