Healthcare Provider Details

I. General information

NPI: 1629530829
Provider Name (Legal Business Name): MR. NICHOLAS GROULX
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 HOLLYWOOD BLVD
HOLLYWOOD FL
33021-6760
US

IV. Provider business mailing address

100 NW 76TH AVE APT 309
PLANTATION FL
33324-2030
US

V. Phone/Fax

Practice location:
  • Phone: 954-822-4175
  • Fax:
Mailing address:
  • Phone: 754-243-4928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-472319
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: