Provider Demographics
NPI:1245459189
Name:NICKSON, MARY TROTTY (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:TROTTY
Last Name:NICKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:TROTTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:807 RIDGEMONT DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002-5075
Mailing Address - Country:US
Mailing Address - Phone:972-396-1970
Mailing Address - Fax:
Practice Address - Street 1:100 ALLENTOWN PKWY
Practice Address - Street 2:#114
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-4200
Practice Address - Country:US
Practice Address - Phone:972-747-0059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11170101YP2500X
TX25148103TC1900X
TX30454103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00U31FMedicare ID - Type UnspecifiedPSYCHOLOGICAL SERVICES