Healthcare Provider Details

I. General information

NPI: 1356814313
Provider Name (Legal Business Name): NANETTE FODELL LCDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2019
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12335 HYMEADOW DR STE 300
AUSTIN TX
78750-1935
US

IV. Provider business mailing address

4500 E OLTORF ST APT 406
AUSTIN TX
78741-4651
US

V. Phone/Fax

Practice location:
  • Phone: 512-250-9355
  • Fax: 512-250-0229
Mailing address:
  • Phone: 214-620-7357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14616
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: