Provider Demographics
NPI:1598645723
Name:EZELL, MICHELLE NICOLE
Entity type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:NICOLE
Last Name:EZELL
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 1:2100 E BROAD ST APT 2351
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4763
Mailing Address - Country:US
Mailing Address - Phone:817-875-1579
Mailing Address - Fax:
Practice Address - Street 1:1720 OAK VILLAGE BLVD STE 200B
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-7952
Practice Address - Country:US
Practice Address - Phone:682-282-6858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202813106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist