Provider Demographics
NPI:1316303183
Name:IREDALE, NICOLE ANNE (LPC, NCC)
Entity type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:ANNE
Last Name:IREDALE
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8307 WILLOW CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-1821
Mailing Address - Country:US
Mailing Address - Phone:210-790-8442
Mailing Address - Fax:
Practice Address - Street 1:8535 TOM SLICK
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3367
Practice Address - Country:US
Practice Address - Phone:210-616-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70037101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional