Provider Demographics
NPI:1073184636
Name:NICKERSON, MIA (MD)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9264 SILVER DOLLAR DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76131-1922
Mailing Address - Country:US
Mailing Address - Phone:951-640-9068
Mailing Address - Fax:
Practice Address - Street 1:5750 RUFE SNOW DR
Practice Address - Street 2:
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180-6163
Practice Address - Country:US
Practice Address - Phone:682-207-7233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional