Provider Demographics
NPI:1144577958
Name:MABRY, NICOLE R (PHD)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:R
Last Name:MABRY
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 1:7272 WURZBACH RD
Mailing Address - Street 2:SUITE 601
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-4801
Mailing Address - Country:US
Mailing Address - Phone:210-615-3483
Mailing Address - Fax:210-593-9863
Practice Address - Street 1:7272 WURZBACH RD
Practice Address - Street 2:SUITE 601
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-4801
Practice Address - Country:US
Practice Address - Phone:210-615-3483
Practice Address - Fax:210-593-9863
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65777101YP2500X
TX36997103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX36997OtherPHD
TX65777OtherLPC LICENSE