Provider Demographics
NPI:1063835346
Name:NICHOLS, SHELLEY BLANCETT (PHD)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:BLANCETT
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:LYNN
Other - Last Name:BLANCETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1030 ANDREWS HWY
Mailing Address - Street 2:STE 105-H
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-3895
Mailing Address - Country:US
Mailing Address - Phone:432-620-5800
Mailing Address - Fax:
Practice Address - Street 1:1030 ANDREWS HWY
Practice Address - Street 2:STE 105-H
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701
Practice Address - Country:US
Practice Address - Phone:432-247-1221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-22
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19072101YP2500X
TX36329103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional