=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811234016
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NESTOR DOMINIC ST. CHARLES L.M.H.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2013
-----------------------------------------------------
Last Update Date | 01/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 N UNIVERSITY DR SUITE 116A
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33071-6096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-464-1570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10701 NW 24TH ST
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33065-3668
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-464-1570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH 11369
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------