Provider Demographics
NPI:1639719974
Name:STACKPOLE, NICOLE (LPC, R-DMT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:STACKPOLE
Suffix:
Gender:F
Credentials:LPC, R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2915 AFTONSHIRE WAY APT 9301
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-5883
Mailing Address - Country:US
Mailing Address - Phone:512-643-0840
Mailing Address - Fax:
Practice Address - Street 1:112 CIMARRON PARK LOOP STE B
Practice Address - Street 2:
Practice Address - City:BUDA
Practice Address - State:TX
Practice Address - Zip Code:78610-2850
Practice Address - Country:US
Practice Address - Phone:512-643-0840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX79813101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor