Healthcare Provider Details

I. General information

NPI: 1174460216
Provider Name (Legal Business Name): KARL NICOLAEV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15935 NW 57TH AVE
MIAMI LAKES FL
33014-6703
US

IV. Provider business mailing address

2100 SANS SOUCI BLVD APT 711
NORTH MIAMI FL
33181-3024
US

V. Phone/Fax

Practice location:
  • Phone: 786-801-7577
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW20122
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: