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General NPI Number Information
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NPI Number | 1003356577
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Entity Type | Individual
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Provider Name | NICOLE JUSTINE BROGDON MAC LPC LMFT
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Gender | Female
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Dates
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Enumeration Date | 03/03/2017
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Last Update Date | 03/03/2017
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Provider Practice Location Address
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Address Line | 2720 BEE CAVES RD
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City | AUSTIN
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State | TX
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Zip | 78746-5642
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Country | US
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Telephone | 512-217-5247
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Fax | 512-732-0556
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Provider Business Mailing Address
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Address Line | 2720 BEE CAVES RD
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City | AUSTIN
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State | TX
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Zip | 78746-5642
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Country | US
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Telephone | 512-217-5247
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Fax | 512-732-0556
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 63068
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 201143
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License Number State | TX
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