Healthcare Provider Details

I. General information

NPI: 1679863237
Provider Name (Legal Business Name): NICOLE M VENDETTE BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
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: 772-209-6900
Mailing address:
  • Phone: 407-947-4675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number11410241
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number11410241
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: