Provider Demographics
NPI:1114052289
Name:NICOLETTE, LISA MARIE (MS, LMHC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:NICOLETTE
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 SW CERTOSA RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1369
Mailing Address - Country:US
Mailing Address - Phone:772-206-1249
Mailing Address - Fax:
Practice Address - Street 1:906 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-8518
Practice Address - Country:US
Practice Address - Phone:772-202-5661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLMH22494101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health