Healthcare Provider Details

I. General information

NPI: 1003332537
Provider Name (Legal Business Name): NICOLE ELISE CAVALLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2017
Last Update Date: 08/31/2025
Certification Date: 08/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 MAIN ST STE 101
WESTON FL
33326-3648
US

IV. Provider business mailing address

2925 NE 199TH ST
AVENTURA FL
33180-3124
US

V. Phone/Fax

Practice location:
  • Phone: 305-936-1002
  • Fax:
Mailing address:
  • Phone: 305-936-1002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY12497
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: