Provider Demographics
NPI:1003356577
Name:BROGDON, NICOLE JUSTINE (MAC LPC LMFT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:JUSTINE
Last Name:BROGDON
Suffix:
Gender:F
Credentials:MAC LPC LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 BEE CAVES RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-5642
Mailing Address - Country:US
Mailing Address - Phone:512-217-5247
Mailing Address - Fax:512-732-0556
Practice Address - Street 1:2720 BEE CAVES RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-5642
Practice Address - Country:US
Practice Address - Phone:512-217-5247
Practice Address - Fax:512-732-0556
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-03
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63068101YP2500X
TX201143106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist