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1821311606 NPI number — NICOLE BROADWAY WALLACE LPCC

NPI Number: 1821311606
Health Care Provider/Practitioner: NICOLE BROADWAY WALLACE LPCC

Information about “1821311606” NPI (NICOLE BROADWAY WALLACE LPCC) exists in 1821311606 in HTML format HTML  |  1821311606 in plain Text format TXT  |  1821311606 in PDF (Portable Document Format) PDF  |  1821311606 in an XML format XML  formats.

NPI Number : 1821311606 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1821311606",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "WALLACE",
    "FirstName": "NICOLE",
    "MiddleName": "BROADWAY",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "LPCC",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "BROADWAY",
    "OtherFirstName": "NICOLE",
    "OtherMiddleName": "JANE",
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": "1",
    "FirstLineMailingAddress": "2201 S. WS YOUNG DR",
    "SecondLineMailingAddress": "SUITE 106-C OFFICE 105",
    "MailingAddressCityName": "KILLEEN",
    "MailingAddressStateName": "TX",
    "MailingAddressPostalCode": "76543",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "254-630-7450",
    "MailingAddressFaxNumber": "254-853-4241",
    "FirstLinePracticeLocationAddress": "207 BELO DR",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "KILLEEN",
    "PracticeLocationAddressStateName": "TX",
    "PracticeLocationAddressPostalCode": "76542-5598",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "254-630-7450",
    "PracticeLocationAddressFaxNumber": "254-853-4241",
    "EnumerationDate": "03/08/2010",
    "LastUpdateDate": "06/23/2025",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "101YP2500X",
          "TaxonomyName": "Professional Counselor",
          "LicenseNumber": "19501",
          "LicenseNumberStateCode": "TX",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "101YP2500X",
          "TaxonomyName": "Professional Counselor",
          "LicenseNumber": "9626",
          "LicenseNumberStateCode": "CA",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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