Provider Demographics
NPI:1194134528
Name:SIEGEL, NICOLE (LCSW, LCDC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:LCSW, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4142 PETERSBURG DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-4373
Mailing Address - Country:US
Mailing Address - Phone:682-593-1272
Mailing Address - Fax:817-488-9656
Practice Address - Street 1:2485 E SOUTHLAKE BLVD STE 180
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6687
Practice Address - Country:US
Practice Address - Phone:682-593-1272
Practice Address - Fax:817-488-9697
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11330101YA0400X
TX574441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)