Provider Demographics
NPI:1588703813
Name:CARRASCO, NICOLAS (PHD)
Entity type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:CARRASCO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 COQUINA LN
Mailing Address - Street 2:
Mailing Address - City:WEST LAKE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78746-4503
Mailing Address - Country:US
Mailing Address - Phone:512-845-2400
Mailing Address - Fax:
Practice Address - Street 1:314 E HIGHLAND MALL BLVD STE 252
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752-3766
Practice Address - Country:US
Practice Address - Phone:512-845-7105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9434103TF0200X
TX24685103T00000X
TX30041103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00J73PMedicare ID - Type Unspecified