Healthcare Provider Details

I. General information

NPI: 1578283867
Provider Name (Legal Business Name): NICOLE ELDRIDGE MARCUS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7685 SW 104TH ST STE 100
PINECREST FL
33156-3161
US

IV. Provider business mailing address

7685 SW 104TH ST STE 100
PINECREST FL
33156-3161
US

V. Phone/Fax

Practice location:
  • Phone: 305-877-3333
  • Fax:
Mailing address:
  • Phone: 305-877-3333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY7161
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: