Healthcare Provider Details

I. General information

NPI: 1962071027
Provider Name (Legal Business Name): NICOLE CAMILA SAN MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 01/20/2026
Certification Date: 01/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3081 SALZEDO ST STE 202
CORAL GABLES FL
33134-6725
US

IV. Provider business mailing address

221 N MELROSE DR
MIAMI SPRINGS FL
33166-5027
US

V. Phone/Fax

Practice location:
  • Phone: 786-708-1532
  • Fax:
Mailing address:
  • Phone: 786-708-1532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH28814
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: