Provider Demographics
NPI:1952025587
Name:NICODEMUS, KRYSTAL (LPC)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:NICODEMUS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:
Other - Last Name:NICODEMUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4645 AVON LN STE 190B
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-1549
Mailing Address - Country:US
Mailing Address - Phone:972-259-0109
Mailing Address - Fax:
Practice Address - Street 1:777 INTERNATIONAL PKWY STE 260
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022-5303
Practice Address - Country:US
Practice Address - Phone:972-221-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX85621101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health