Provider Demographics
NPI:1972904159
Name:BLANK, NICOLE (PSYD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:BLANK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:BLANK
Other - Last Name:KOLES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:2840 SW 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33129-2317
Mailing Address - Country:US
Mailing Address - Phone:305-857-0050
Mailing Address - Fax:
Practice Address - Street 1:2840 SW 3RD AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33129-2317
Practice Address - Country:US
Practice Address - Phone:305-857-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9074103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist