Provider Demographics
NPI:1063881589
Name:CEUSTERS, NICOLE (MS, LMHC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CEUSTERS
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:GEAR
Other - Middle Name:
Other - Last Name:COUNSELING LLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:6700 NW 26TH TER
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-1304
Mailing Address - Country:US
Mailing Address - Phone:561-876-2304
Mailing Address - Fax:
Practice Address - Street 1:6700 NW 26TH TER
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-1304
Practice Address - Country:US
Practice Address - Phone:561-876-2304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2022-04-07
Deactivation Date:2018-05-28
Deactivation Code:
Reactivation Date:2022-01-12
Provider Licenses
StateLicense IDTaxonomies
FLMH20111101YM0800X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000950352Medicaid