Provider Demographics
NPI:1730521808
Name:MACCALLUM, NICOLE LEE (LPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:MACCALLUM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LEE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 1728
Mailing Address - Street 2:
Mailing Address - City:GROVES
Mailing Address - State:TX
Mailing Address - Zip Code:77619-1728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4934 ATLANTIC RD
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-0165
Practice Address - Country:US
Practice Address - Phone:409-926-6732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68625101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional