Provider Demographics
NPI:1174831176
Name:NICOLAS, MAGALIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MAGALIE
Middle Name:
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6461 BORASCO DR
Mailing Address - Street 2:UNIT # 2802
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6143
Mailing Address - Country:US
Mailing Address - Phone:305-849-2559
Mailing Address - Fax:
Practice Address - Street 1:190 MCIVER LN
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-5412
Practice Address - Country:US
Practice Address - Phone:321-631-8569
Practice Address - Fax:321-631-6530
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL100331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002750900Medicaid