Provider Demographics
NPI:1043380116
Name:NICOLAS, MARIO GEORGE (PHD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:GEORGE
Last Name:NICOLAS
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 1:1100 WILFORD HALL LOOP BLDG 4554
Mailing Address - Street 2:
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5638
Mailing Address - Country:US
Mailing Address - Phone:210-292-6225
Mailing Address - Fax:
Practice Address - Street 1:1100 WILFORD HALL LOOP, BLDG 4554
Practice Address - Street 2:ATTN: 59 MDW/SGHC
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236
Practice Address - Country:US
Practice Address - Phone:210-292-6225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37499103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist