Provider Demographics
NPI:1386736866
Name:NICK, NOEL NANI (PSYD)
Entity type:Individual
Prefix:
First Name:NOEL
Middle Name:NANI
Last Name:NICK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 348
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78403-0348
Mailing Address - Country:US
Mailing Address - Phone:361-883-9110
Mailing Address - Fax:361-887-1080
Practice Address - Street 1:101 N SHORELINE BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78401-2824
Practice Address - Country:US
Practice Address - Phone:361-883-9110
Practice Address - Fax:361-887-1080
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI779103TC0700X
TX34031103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F9763OtherMEDICARE INDIVIDUAL TPAN