Provider Demographics
NPI:1356814313
Name:FODELL, NANETTE (LCDC)
Entity Type:Individual
Prefix:
First Name:NANETTE
Middle Name:
Last Name:FODELL
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 E OLTORF ST APT 406
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741-4651
Mailing Address - Country:US
Mailing Address - Phone:214-620-7357
Mailing Address - Fax:
Practice Address - Street 1:12335 HYMEADOW DR STE 300
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-1935
Practice Address - Country:US
Practice Address - Phone:512-250-9355
Practice Address - Fax:512-250-0229
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14616101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)