Provider Demographics
NPI:1275929689
Name:KEITH, NICOLE (LMFT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KEITH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 S CYPRESS BEND DR APT 507
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33069-4431
Mailing Address - Country:US
Mailing Address - Phone:954-909-6787
Mailing Address - Fax:
Practice Address - Street 1:2208 S CYPRESS BEND DR APT 507
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33069-4431
Practice Address - Country:US
Practice Address - Phone:804-356-8736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-13
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT4546106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist