Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 63068 | TX |
NPI | 1003356577 |
---|---|
Provider Name | Nicole Justine Brogdon |
First Address | Austin, TX 78746-5642 |
Second Address | Austin, TX 78746-5642 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/03/2017 |
Last Update Date | 03/03/2017 |