Provider Demographics
NPI:1124839956
Name:HARTZOG, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HARTZOG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 E BALDWIN RD UNIT M
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4286
Mailing Address - Country:US
Mailing Address - Phone:850-527-7063
Mailing Address - Fax:
Practice Address - Street 1:640 S HIGHWAY 22 A
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-6824
Practice Address - Country:US
Practice Address - Phone:850-767-4570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool