Provider Demographics
NPI:1316951247
Name:DIDRIKSEN, NANCY A (PHD)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:A
Last Name:DIDRIKSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:997 HAMPSHIRE LANE
Mailing Address - Street 2:STE 200
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-8104
Mailing Address - Country:US
Mailing Address - Phone:972-889-9933
Mailing Address - Fax:972-889-9935
Practice Address - Street 1:997 HAMPSHIRE LANE
Practice Address - Street 2:STE 200
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-8104
Practice Address - Country:US
Practice Address - Phone:972-889-9933
Practice Address - Fax:972-889-9935
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23529103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
179804900OtherUS DEPT OF LABOR
TX179804900OtherOWCP INDIVIDUAL PROVIDER
TX680009955OtherRR MEDICARE PROVIDER #