Provider Demographics
NPI:1821311606
Name:WALLACE, NICOLE BROADWAY (LPC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:BROADWAY
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:JANE
Other - Last Name:BROADWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2201 S. WS YOUNG DR
Mailing Address - Street 2:SUITE 106-C OFFICE 105
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543
Mailing Address - Country:US
Mailing Address - Phone:254-630-7450
Mailing Address - Fax:254-853-4241
Practice Address - Street 1:207 BELO DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-5598
Practice Address - Country:US
Practice Address - Phone:254-630-7450
Practice Address - Fax:254-853-4241
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19501101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional