Healthcare Provider Details

I. General information

NPI: 1558596304
Provider Name (Legal Business Name): AMY REBECCA NICHOLS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2009
Last Update Date: 05/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 SAMUELL BLVD
DALLAS TX
75228-6828
US

IV. Provider business mailing address

4701 SAMUELL BLVD
DALLAS TX
75228-6828
US

V. Phone/Fax

Practice location:
  • Phone: 214-381-7070
  • Fax:
Mailing address:
  • Phone: 214-381-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number64110
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: