Healthcare Provider Details

I. General information

NPI: 1629388830
Provider Name (Legal Business Name): NICOLE ENNIS WHITEHEAD PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD BOX 100166
GAINESVILLE FL
32610-0166
US

IV. Provider business mailing address

PO BOX 100166
GAINESVILLE FL
32610-0166
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0294
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY7458
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: