Healthcare Provider Details

I. General information

NPI: 1669899977
Provider Name (Legal Business Name): NICOLE JULIANA DEWITT M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: N.JULIANA DEWITT M.S.

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N PERKINS RD N16
STILLWATER OK
74075-7104
US

IV. Provider business mailing address

6117 KING ST UNIT A
GREENVILLE TX
75402-8995
US

V. Phone/Fax

Practice location:
  • Phone: 253-330-3175
  • Fax:
Mailing address:
  • Phone: 253-330-3175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number84227
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: