1548564883 NPI number — NICOLE LATRECE NICHOLS LMHC

Table of content: NICOLE LATRECE NICHOLS LMHC (NPI 1548564883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548564883 NPI number — NICOLE LATRECE NICHOLS LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLS
Provider First Name:
NICOLE
Provider Middle Name:
LATRECE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548564883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4300 SW 13TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32608-4006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-374-5600
Provider Business Mailing Address Fax Number:
352-374-5608

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
945 GRAND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STARKE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32091-1821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-374-5600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/30/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 012410600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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