Provider Demographics
NPI:1386258994
Name:HEAD, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HEAD
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 1:11517 SOUTHERN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-5355
Mailing Address - Country:US
Mailing Address - Phone:813-765-9649
Mailing Address - Fax:
Practice Address - Street 1:12197 W LINEBAUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1732
Practice Address - Country:US
Practice Address - Phone:813-727-0264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty