1457690174 NPI number — CALLY ELIZABETH NICHOLSON M.S., L.P.C.

Table of content: CALLY ELIZABETH NICHOLSON M.S., L.P.C. (NPI 1457690174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457690174 NPI number — CALLY ELIZABETH NICHOLSON M.S., L.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLSON
Provider First Name:
CALLY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., L.P.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AGNOR
Provider Other First Name:
CALLY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S., L.P.C.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457690174
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75606-4207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-315-4119
Provider Business Mailing Address Fax Number:
903-315-4130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 W LOOP 281
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75604-2506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-315-2620
Provider Business Practice Location Address Fax Number:
903-315-3513
Provider Enumeration Date:
02/01/2013

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:  66250 , 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)





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