Provider Demographics
NPI:1407546542
Name:MARK, NICOLE MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:MARK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1601 CONRAD HILTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CISCO
Mailing Address - State:TX
Mailing Address - Zip Code:76437-4346
Mailing Address - Country:US
Mailing Address - Phone:254-247-7328
Mailing Address - Fax:
Practice Address - Street 1:1601 CONRAD HILTON BLVD
Practice Address - Street 2:
Practice Address - City:CISCO
Practice Address - State:TX
Practice Address - Zip Code:76437-4346
Practice Address - Country:US
Practice Address - Phone:254-247-7328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69418104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker