MEDICARE: MRS. NINOSHKA NICOLE VIDRO

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
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1598510265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NINOSHKA NICOLE VIDRO

Provider Business Mailing Address
First Line	:	2073 LAUREL LN
Second Line	:
City	:	NORTH FORT MYERS
State	:	FL
Zip	:	33917-6223
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2073 LAUREL LN
Second Line	:
City	:	NORTH FORT MYERS
State	:	FL
Zip	:	33917-6223
Country	:	US
Telephone Number	:	407-640-8658
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2024
Last Update Date	:	04/17/2024

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