Provider Demographics
NPI:1245770197
Name:UNDERWOOD, NICKY (LCSW)
Entity Type:Individual
Prefix:
First Name:NICKY
Middle Name:
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1941 EAST RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-6010
Mailing Address - Country:US
Mailing Address - Phone:713-486-2700
Mailing Address - Fax:713-486-2721
Practice Address - Street 1:3610 STAGG DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-3713
Practice Address - Country:US
Practice Address - Phone:409-730-4700
Practice Address - Fax:409-730-4701
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-26
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX599861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical