Provider Demographics
NPI:1225332711
Name:NISSLEY, GERALD EDWARD JR (PSYD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:EDWARD
Last Name:NISSLEY
Suffix:JR
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 E TRAVIS ST STE 105
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75670-4280
Mailing Address - Country:US
Mailing Address - Phone:903-471-0274
Mailing Address - Fax:800-915-4057
Practice Address - Street 1:505 E TRAVIS ST STE 105
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-4280
Practice Address - Country:US
Practice Address - Phone:903-471-0274
Practice Address - Fax:800-915-4057
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-27
Last Update Date:2023-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34733103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical