Provider Demographics
NPI:1811151582
Name:NICHOLSON, MISTI
Entity type:Individual
Prefix:
First Name:MISTI
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MISTI
Other - Middle Name:MICHELLE
Other - Last Name:TUERCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3000 JOE DIMAGGIO BLVD
Mailing Address - Street 2:SUITE 66
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-3922
Mailing Address - Country:US
Mailing Address - Phone:512-246-7225
Mailing Address - Fax:
Practice Address - Street 1:3000 JOE DIMAGGIO BLVD
Practice Address - Street 2:SUITE 66
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-3922
Practice Address - Country:US
Practice Address - Phone:512-246-7225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36270103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent