=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972219640
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE MUSCARELLA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2023
-----------------------------------------------------
Last Update Date | 01/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 KENMORE LN
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33435-7309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-727-4718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6282 DUPONT STATION CT E STE A
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32217-2515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-727-4718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | ICADC.0000040
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------