Healthcare Provider Details

I. General information

NPI: 1639770423
Provider Name (Legal Business Name): NICKOLE MARGUERITE WYSE MS, LMHC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 4TH ST N STE 4000
ST PETERSBURG FL
33702-4305
US

IV. Provider business mailing address

633 QUILLETTE ST
BEAVERTON MI
48612-8625
US

V. Phone/Fax

Practice location:
  • Phone: 561-490-9117
  • Fax:
Mailing address:
  • Phone: 989-942-2687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH18325
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: