Provider Demographics
NPI:1437569324
Name:WALL, NICHELLE M (M ED, LPC, CST-C)
Entity Type:Individual
Prefix:
First Name:NICHELLE
Middle Name:M
Last Name:WALL
Suffix:
Gender:F
Credentials:M ED, LPC, CST-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1169 N BURLESON BLVD
Mailing Address - Street 2:107 PMB 242
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7011
Mailing Address - Country:US
Mailing Address - Phone:214-396-6503
Mailing Address - Fax:469-359-6729
Practice Address - Street 1:1264 HARWOOD RD
Practice Address - Street 2:175
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-4267
Practice Address - Country:US
Practice Address - Phone:214-396-6503
Practice Address - Fax:469-359-6729
Is Sole Proprietor?:No
Enumeration Date:2014-05-01
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69796101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX220346501Medicaid