Healthcare Provider Details

I. General information

NPI: 1215637467
Provider Name (Legal Business Name): NICOLAS CARRASCO, PHD., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 E HIGHLAND MALL BLVD STE 252
AUSTIN TX
78752-3766
US

IV. Provider business mailing address

502 COQUINA LN
WEST LAKE HILLS TX
78746-4503
US

V. Phone/Fax

Practice location:
  • Phone: 512-845-2400
  • Fax:
Mailing address:
  • Phone: 512-845-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: NICOLAS CARRASCO
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PHD
Phone: 512-845-7105