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General NPI Number Information
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NPI Number | 1194134528
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Entity Type | Individual
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Provider Name | NICOLE SIEGEL LCSW, LCDC
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Gender | Female
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Dates
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Enumeration Date | 08/11/2014
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Last Update Date | 04/26/2017
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Provider Practice Location Address
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Address Line | 2485 E SOUTHLAKE BLVD STE 180
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City | SOUTHLAKE
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State | TX
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Zip | 76092-6687
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Country | US
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Telephone | 682-593-1272
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Fax | 817-488-9697
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Provider Business Mailing Address
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Address Line | 4142 PETERSBURG DR
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City | FORT WORTH
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State | TX
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Zip | 76244-4373
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Country | US
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Telephone | 682-593-1272
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Fax | 817-488-9656
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 11330
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 57444
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License Number State | TX
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