Provider Demographics
NPI:1942031448
Name:GILLIAM, NICKOLE (LPC)
Entity type:Individual
Prefix:
First Name:NICKOLE
Middle Name:
Last Name:GILLIAM
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 1:406 CIRCLESTONE CT
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:SC
Mailing Address - Zip Code:29369-8906
Mailing Address - Country:US
Mailing Address - Phone:864-905-0633
Mailing Address - Fax:
Practice Address - Street 1:84 GROCE RD
Practice Address - Street 2:
Practice Address - City:LYMAN
Practice Address - State:SC
Practice Address - Zip Code:29365-1761
Practice Address - Country:US
Practice Address - Phone:864-439-7760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7915101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health