1184115313 NPI number — NICOLE BEREOLOS, PHD, PLLC

Table of content: (NPI 1184115313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184115313 NPI number — NICOLE BEREOLOS, PHD, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NICOLE BEREOLOS, PHD, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184115313
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2033 W MCDERMOTT DR, STE 320
Provider Second Line Business Mailing Address:
#184
Provider Business Mailing Address City Name:
ALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75013-4675
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9330 LBJ FWY STE 900
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75243-3443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-768-7994
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BEREOLOS
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
972-768-7994

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 289346301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 60054 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0012XH . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1427341825 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3809908 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 600766136 . This is a "MAGELLAN" identifier . This identifiers is of the category "OTHER".




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