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NPI Code Detail

MEDICARE: KELLY LYNN NICOLAUS LCSW

MEDICARE: KELLY LYNN NICOLAUS LCSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker17352FL

General Provider Information

NPI Number : 1245909365
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY LYNN NICOLAUS LCSW
Provider Business Mailing Address
First Line : 4520 OAK FAIR BLVD
Second Line :
City : TAMPA
State : FL
Zip : 33610-7356
Country : US
Telephone Number : 814-441-5751
Fax Number :
Provider Business Practice Location Address
First Line : 4520 OAK FAIR BLVD
Second Line :
City : TAMPA
State : FL
Zip : 33610-7356
Country : US
Telephone Number : 813-532-5500
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/10/2021
Last Update Date : 02/04/2024

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Directions to “ KELLY LYNN NICOLAUS LCSW” Practice Location

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