Healthcare Provider Details

I. General information

NPI: 1851744767
Provider Name (Legal Business Name): NICOLE STEPHANIE MENZIE M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13000 BRUCE B DOWNS BLVD PSYCHOLOGY TRAILER 59
TAMPA FL
33612-4745
US

IV. Provider business mailing address

19301 RED SKY CT
LAND O LAKES FL
34638-6183
US

V. Phone/Fax

Practice location:
  • Phone: 813-972-2000
  • Fax:
Mailing address:
  • Phone: 305-343-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: