Provider Demographics
NPI:1861137507
Name:REAVY, NICOLE MARIE (LPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:REAVY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5127 WILLIAMS FORK TRL APT 208
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3464
Mailing Address - Country:US
Mailing Address - Phone:206-430-9407
Mailing Address - Fax:
Practice Address - Street 1:5127 WILLIAMS FORK TRL APT 208
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3464
Practice Address - Country:US
Practice Address - Phone:206-430-9407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0018222101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional