Provider Demographics
NPI:1316764590
Name:BAZACO, NICOLE RAE (LPC-A)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAE
Last Name:BAZACO
Suffix:
Gender:F
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4709 CHERRY BARK TRL
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76005-1323
Mailing Address - Country:US
Mailing Address - Phone:512-658-0253
Mailing Address - Fax:
Practice Address - Street 1:7165 COLLEYVILLE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-8011
Practice Address - Country:US
Practice Address - Phone:817-697-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX89734101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional