Healthcare Provider Details

I. General information

NPI: 1982140307
Provider Name (Legal Business Name): NICOLLE M BAUER LMHC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 N PONCE DE LEON BLVD STE 3
ST AUGUSTINE FL
32084-2600
US

IV. Provider business mailing address

2200 N PONCE DE LEON BLVD STE 3
ST AUGUSTINE FL
32084-2600
US

V. Phone/Fax

Practice location:
  • Phone: 904-501-8270
  • Fax: 904-819-5330
Mailing address:
  • Phone: 904-501-8270
  • Fax: 904-819-5330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH6243
License Number StateFL

VIII. Authorized Official

Name: NICOLLE M BAUER
Title or Position: OWNER
Credential: LMHC
Phone: 904-501-8270