Healthcare Provider Details

I. General information

NPI: 1801707229
Provider Name (Legal Business Name): NICOLE GREENBERG
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 DELTA CT
TALLAHASSEE FL
32303-4875
US

IV. Provider business mailing address

215 DELTA CT
TALLAHASSEE FL
32303-4875
US

V. Phone/Fax

Practice location:
  • Phone: 850-270-7294
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number12454
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: