Active NPI
Nicquelette Ellison
- Psychologist
- Tyler, TX
National Provider Identifier
1912745472
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- Practice address
- 2830 W Grande Blvd Apt 3102
Tyler, TX 75703-3392 - Phone
- (813) 919-5860
- NPI assigned
- Jul 18, 2024
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | TX | Primary |
Addresses
Primary practice location
2830 W Grande Blvd Apt 3102
Tyler, TX 75703-3392
Mailing address
2830 W Grande Blvd Apt 3102
Tyler, TX 75703-3392
Phone (813) 919-5860
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Jan 13, 2026 through Jan 13, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 40960 | TX | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Psychology Express Inc | Psychologist | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Psychologist
- Cypress, TX
- NPI 1629591771
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1721260800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1759881600000",
"number": "1912745472",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2830 W GRANDE BLVD APT 3102",
"city": "TYLER",
"state": "TX",
"postal_code": "757033392",
"telephone_number": "813-919-5860"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2830 W GRANDE BLVD APT 3102",
"city": "TYLER",
"state": "TX",
"postal_code": "757033392",
"telephone_number": "813-919-5860"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ELLISON",
"first_name": "NICQUELETTE",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2024-07-18",
"last_updated": "2025-10-08",
"certification_date": "2025-10-08",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "TX",
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Tyler, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 8, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.