Healthcare Provider Details

I. General information

NPI: 1265190672
Provider Name (Legal Business Name): NICOLE SMITH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 4TH ST N STE 300
SAINT PETERSBURG FL
33702-4399
US

IV. Provider business mailing address

7901 4TH ST N STE 300
SAINT PETERSBURG FL
33702-4399
US

V. Phone/Fax

Practice location:
  • Phone: 615-964-1883
  • Fax:
Mailing address:
  • Phone: 615-964-1883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9479
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW26444
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number116778
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: