Provider Demographics
NPI:1376041640
Name:TEDESCO, NICOLE AMBER (LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLE AMBER
Middle Name:
Last Name:TEDESCO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2469 GLENRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-3933
Mailing Address - Country:US
Mailing Address - Phone:352-835-1955
Mailing Address - Fax:
Practice Address - Street 1:17222 HOSPITAL BLVD STE 116
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-8925
Practice Address - Country:US
Practice Address - Phone:352-678-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW151021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical