Healthcare Provider Details

I. General information

NPI: 1629540463
Provider Name (Legal Business Name): BRITTANY NICOLE NYBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4287 RUES LANDING RD
SAINT AUGUSTINE FL
32092-0647
US

IV. Provider business mailing address

515 PALM COAST PKWY SW STE 6
PALM COAST FL
32137-5700
US

V. Phone/Fax

Practice location:
  • Phone: 724-747-2314
  • Fax:
Mailing address:
  • Phone: 386-951-3044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: