Healthcare Provider Details

I. General information

NPI: 1205356227
Provider Name (Legal Business Name): NICOLE MARIE VACCARO PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 06/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17734 HUNTING BOW CIR STE 101
LUTZ FL
33558-5383
US

IV. Provider business mailing address

12017 TUSCANY BAY DR APT 301
TAMPA FL
33626-1369
US

V. Phone/Fax

Practice location:
  • Phone: 813-443-5311
  • Fax:
Mailing address:
  • Phone: 941-600-1014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH11745
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: