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General NPI Number Information
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NPI Number | 1073184636
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Entity Type | Individual
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Provider Name | MIA NICKERSON MD
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Gender | Female
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Dates
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Enumeration Date | 07/06/2021
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Last Update Date | 07/06/2021
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Provider Practice Location Address
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Address Line | 5750 RUFE SNOW DR
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City | NORTH RICHLAND HILLS
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State | TX
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Zip | 76180-6163
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Country | US
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Telephone | 682-207-7233
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Fax |
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Provider Business Mailing Address
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Address Line | 9264 SILVER DOLLAR DR
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City | FORT WORTH
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State | TX
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Zip | 76131-1922
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Country | US
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Telephone | 951-640-9068
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Fax |
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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 |
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License Number State | TX
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