Provider Demographics
NPI:1154542918
Name:SAN NICOLAS, ROSEMARY (MS)
Entity type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:
Last Name:SAN NICOLAS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3785 NW 82ND AVE
Mailing Address - Street 2:408
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9380 SW 72 ST.
Practice Address - Street 2:SUITE B-250
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-5454
Practice Address - Country:US
Practice Address - Phone:305-274-3738
Practice Address - Fax:305-274-3172
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9864101YM0800X
FL1-15-19388103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health