Provider Demographics
NPI:1235670142
Name:GENEREUX, NICOLE KELLY
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:KELLY
Last Name:GENEREUX
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 1:17335 PAGONIA DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6011
Mailing Address - Country:US
Mailing Address - Phone:352-223-4123
Mailing Address - Fax:
Practice Address - Street 1:17335 PAGONIA DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6011
Practice Address - Country:US
Practice Address - Phone:352-223-4123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-10
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician