Basic Information
Provider Information | |||||||||
NPI: | 1982110508 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KEMP | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KEMP | ||||||||
OtherFirstName: | NICOLE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MS | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 3203 HAWTHORNE AVE | ||||||||
Address2: |   | ||||||||
City: | ROCKLEDGE | ||||||||
State: | FL | ||||||||
PostalCode: | 329554354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3216314578 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7 N COCOA BLVD | ||||||||
Address2: |   | ||||||||
City: | COCOA | ||||||||
State: | FL | ||||||||
PostalCode: | 329227749 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3216314578 | ||||||||
FaxNumber: | 3216314578 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/19/2017 | ||||||||
LastUpdateDate: | 12/19/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X |   | FL | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.