Provider Demographics
NPI:1417514779
Name:BERMEJILLO, NICOLE R
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:BERMEJILLO
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 1:6800 PARK TEN BLVD STE 200S
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-4293
Mailing Address - Country:US
Mailing Address - Phone:210-261-1000
Mailing Address - Fax:210-261-1821
Practice Address - Street 1:315 N SAN SABA STE 1003
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3100
Practice Address - Country:US
Practice Address - Phone:210-261-3100
Practice Address - Fax:210-261-1821
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77924101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional