Provider Demographics
NPI:1225330996
Name:BALT, NICHOLE IONE (BA)
Entity Type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:IONE
Last Name:BALT
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13601 PARKCREST BLVD
Mailing Address - Street 2:APT #1332
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-7104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12550 NEW BRITTANY BLVD
Practice Address - Street 2:STE 200
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3655
Practice Address - Country:US
Practice Address - Phone:239-936-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health