Provider Demographics
NPI:1174115893
Name:BIRKENSTOCK, NICOLE SUE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:SUE
Last Name:BIRKENSTOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2023 HERBERT AKINS RD
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-8300
Mailing Address - Country:US
Mailing Address - Phone:919-442-7936
Mailing Address - Fax:
Practice Address - Street 1:2724 THURROCK DR
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27539-8657
Practice Address - Country:US
Practice Address - Phone:919-442-7936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-04
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16197101YM0800X
NC16197101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health