Provider Demographics
NPI:1336681451
Name:GRIFFITH, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GRIFFITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 COCKRILL CT
Mailing Address - Street 2:
Mailing Address - City:HUTTO
Mailing Address - State:TX
Mailing Address - Zip Code:78634-4504
Mailing Address - Country:US
Mailing Address - Phone:713-540-2301
Mailing Address - Fax:
Practice Address - Street 1:1603 MEDICAL PKWY
Practice Address - Street 2:BUILDING 3, #320
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-7899
Practice Address - Country:US
Practice Address - Phone:713-540-2301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-07
Last Update Date:2017-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73326101YP2500X
TX202446106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist