Healthcare Provider Details

I. General information

NPI: 1558497719
Provider Name (Legal Business Name): NICOLE LYNN VREDENBURG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2007
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4302 W BROWARD BLVD SUITE 800
PLANTATION FL
33317-3780
US

IV. Provider business mailing address

4302 W. BROWARD BLVD. SUITE 800
PLANTATION FL
33317
US

V. Phone/Fax

Practice location:
  • Phone: 954-854-6533
  • Fax:
Mailing address:
  • Phone: 954-854-6533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW9372
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: