Provider Demographics
NPI:1336777036
Name:RICHARDSON, NICOLE JORDAN (LPC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JORDAN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3144 STONE CREEK LN
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3801
Mailing Address - Country:US
Mailing Address - Phone:817-412-1426
Mailing Address - Fax:
Practice Address - Street 1:2301 OLYMPIA DR STE 200
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1855
Practice Address - Country:US
Practice Address - Phone:817-412-1426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-29
Last Update Date:2020-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX78941101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional