Provider Demographics
NPI:1962067744
Name:NICKERSON, EBONY (LPC)
Entity type:Individual
Prefix:MRS
First Name:EBONY
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10300 N CENTRAL EXPY STE 280
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231
Mailing Address - Country:US
Mailing Address - Phone:214-909-9545
Mailing Address - Fax:
Practice Address - Street 1:10300 N CENTRAL EXPY STE 280
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-8666
Practice Address - Country:US
Practice Address - Phone:214-909-9545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71630101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional