Basic Information
| Provider Information | |||||||||
| NPI: | 1720745177 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FYFFE NICKERSON | ||||||||
| FirstName: | NATALIE | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | NICKERSON | ||||||||
| OtherFirstName: | NATALIE | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 915 TODDSMILL TRCE | ||||||||
| Address2: | |||||||||
| City: | TARPON SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346892826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185250936 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1919 N PINELLAS AVE | ||||||||
| Address2: | |||||||||
| City: | TARPON SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346895780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275475200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2021 | ||||||||
| LastUpdateDate: | 11/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.