1437569324 NPI number — NICHELLE M. WALL M. ED., LPC, CST-C

Table of content: NICHELLE M. WALL M. ED., LPC, CST-C (NPI 1437569324)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437569324 NPI number — NICHELLE M. WALL M. ED., LPC, CST-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALL
Provider First Name:
NICHELLE
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M. ED., LPC, CST-C
Provider Gender Code:
F

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:
1437569324
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1169 N BURLESON BLVD
Provider Second Line Business Mailing Address:
107 PMB 242
Provider Business Mailing Address City Name:
BURLESON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76028-7011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-396-6503
Provider Business Mailing Address Fax Number:
469-359-6729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1264 HARWOOD RD
Provider Second Line Business Practice Location Address:
175
Provider Business Practice Location Address City Name:
BEDFORD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76021-4267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-396-6503
Provider Business Practice Location Address Fax Number:
469-359-6729
Provider Enumeration Date:
05/01/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  69796 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 220346501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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