Provider Demographics
NPI:1952141715
Name:CLARK, NICOLLE M (MED)
Entity type:Individual
Prefix:
First Name:NICOLLE
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28330 OAK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78132-3625
Mailing Address - Country:US
Mailing Address - Phone:210-269-0122
Mailing Address - Fax:
Practice Address - Street 1:122 W LINDBERGH BLVD
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-4322
Practice Address - Country:US
Practice Address - Phone:210-701-0525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician