Provider Demographics
NPI:1225327570
Name:HERBERT, NIKKI
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:
Last Name:HERBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36100 LAKE CHASE BLVD UNIT 201
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33541-0936
Mailing Address - Country:US
Mailing Address - Phone:813-368-5067
Mailing Address - Fax:
Practice Address - Street 1:2403 E HENRY AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-4434
Practice Address - Country:US
Practice Address - Phone:813-988-7633
Practice Address - Fax:813-914-0403
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001451200Medicaid