Provider Demographics
NPI:1144754466
Name:NICKEL, KELLI PINAC
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:PINAC
Last Name:NICKEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10430 SILL PRAIRIE DR
Mailing Address - Street 2:
Mailing Address - City:IOWA COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:77583-1662
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 N GORDON ST STE 202
Practice Address - Street 2:
Practice Address - City:ALVIN
Practice Address - State:TX
Practice Address - Zip Code:77511-2373
Practice Address - Country:US
Practice Address - Phone:346-774-1774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor