Provider Demographics
NPI:1346971405
Name:NICOLA, MATIAS ALEN
Entity Type:Individual
Prefix:
First Name:MATIAS
Middle Name:ALEN
Last Name:NICOLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 NE 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-7089
Mailing Address - Country:US
Mailing Address - Phone:786-683-3194
Mailing Address - Fax:
Practice Address - Street 1:323 NE 30TH AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-7089
Practice Address - Country:US
Practice Address - Phone:786-683-3194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician