Provider Demographics
NPI:1578329991
Name:NICELY, TERESA (LCDC-I)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:NICELY
Suffix:
Gender:F
Credentials:LCDC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 WALLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1735
Mailing Address - Country:US
Mailing Address - Phone:806-599-8312
Mailing Address - Fax:
Practice Address - Street 1:1001 WALLACE BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1735
Practice Address - Country:US
Practice Address - Phone:806-599-8312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX58656101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor