MEDICARE: KRYSTAL NICODEMUS LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	85621	TX

General Provider Information

NPI Number	:	1952025587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTAL NICODEMUS LPC

Provider Business Mailing Address
First Line	:	4645 AVON LN STE 190B
Second Line	:
City	:	FRISCO
State	:	TX
Zip	:	75033-1549
Country	:	US
Telephone Number	:	972-259-0109
Fax Number	:

Provider Business Practice Location Address
First Line	:	777 INTERNATIONAL PKWY STE 260
Second Line	:
City	:	FLOWER MOUND
State	:	TX
Zip	:	75022-5303
Country	:	US
Telephone Number	:	972-221-7900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2022
Last Update Date	:	03/14/2024

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