Healthcare Provider Details

I. General information

NPI: 1093298564
Provider Name (Legal Business Name): NICOLE VENDETTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 11/04/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10272 S US HIGHWAY 1
PORT SAINT LUCIE FL
34952-5615
US

IV. Provider business mailing address

3344 NE SANDRA DR
JENSEN BEACH FL
34957-3972
US

V. Phone/Fax

Practice location:
  • Phone: 407-947-4675
  • Fax:
Mailing address:
  • Phone: 407-947-4675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. NICOLE M VENDETTE
Title or Position: OWNER
Credential: BCBA
Phone: 407-947-4675