Provider Demographics
NPI:1043429426
Name:WIGGINS, NICHELLE E (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICHELLE
Middle Name:E
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 200156
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-0156
Mailing Address - Country:US
Mailing Address - Phone:817-744-8355
Mailing Address - Fax:817-744-8356
Practice Address - Street 1:3804 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-3523
Practice Address - Country:US
Practice Address - Phone:817-744-8355
Practice Address - Fax:817-744-8356
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31156103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096940401Medicaid
TX096940401Medicaid