Provider Demographics
NPI:1134666340
Name:NEATHERY, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NEATHERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ALEC
Other - Middle Name:
Other - Last Name:NEATHERY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2027 BLUE ROCK DR APT 104
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-5163
Mailing Address - Country:US
Mailing Address - Phone:941-447-7733
Mailing Address - Fax:
Practice Address - Street 1:5707 N 22ND ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-4350
Practice Address - Country:US
Practice Address - Phone:813-239-8069
Practice Address - Fax:813-231-7324
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker