Healthcare Provider Details

I. General information

NPI: 1881120855
Provider Name (Legal Business Name): NICOLE MARIE HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3217 S MACDILL AVE
TAMPA FL
33629-1719
US

IV. Provider business mailing address

1713 BAYOU GRANDE BLVD NE
ST PETERSBURG FL
33703-1907
US

V. Phone/Fax

Practice location:
  • Phone: 813-284-7941
  • Fax:
Mailing address:
  • Phone: 727-686-4533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-44266
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: