Provider Demographics
NPI:1669899977
Name:DEWITT, NICOLE JULIANA (MS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:JULIANA
Last Name:DEWITT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:N.JULIANA
Other - Middle Name:
Other - Last Name:DEWITT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:6117 KING ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75402-8995
Mailing Address - Country:US
Mailing Address - Phone:253-330-3175
Mailing Address - Fax:
Practice Address - Street 1:1200 N PERKINS RD
Practice Address - Street 2:N16
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-7104
Practice Address - Country:US
Practice Address - Phone:253-330-3175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-25
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX84227101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional