Provider Demographics
NPI:1790843860
Name:NICHOLS, CARRIE
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:NICHOLS
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 1:2931 RIDGE RD
Mailing Address - Street 2:STE. 101, PMB 132
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-6670
Mailing Address - Country:US
Mailing Address - Phone:469-964-0027
Mailing Address - Fax:
Practice Address - Street 1:661 JUSTIN RD
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-4821
Practice Address - Country:US
Practice Address - Phone:469-964-0027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65927101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional