Provider Demographics
NPI:1417508482
Name:TESAR, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:TESAR
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 1:1808 NE 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33305-3524
Mailing Address - Country:US
Mailing Address - Phone:786-223-3735
Mailing Address - Fax:
Practice Address - Street 1:283 PARK BLVD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-8010
Practice Address - Country:US
Practice Address - Phone:305-262-0099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-21
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health