Provider Demographics
NPI:1649613381
Name:GRANT, NICOLE M (M ED, LPC)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:M
Last Name:GRANT
Suffix:
Gender:F
Credentials:M ED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 KENSINGTON DR STE 112
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-2734
Mailing Address - Country:US
Mailing Address - Phone:903-530-2290
Mailing Address - Fax:
Practice Address - Street 1:2624 KENSINGTON DR STE 112
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-2734
Practice Address - Country:US
Practice Address - Phone:903-530-2290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18777101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health