=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184383812
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE BROWN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2021
-----------------------------------------------------
Last Update Date | 12/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1350 SOUTH HICKORY ST
-----------------------------------------------------
City | MELBOURN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-979-1230
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6551 N. ORANGE BLOSSOM TRAIL SUITE 209 PMB 1035
-----------------------------------------------------
City | MOUNT DORA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-979-1230
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW17009
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------