Provider Demographics
NPI:1427536564
Name:MENDIZABAL, NICOLE SUZANNE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SUZANNE
Last Name:MENDIZABAL
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 1:2525 PONCE DE LEON BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-6044
Mailing Address - Country:US
Mailing Address - Phone:786-571-4636
Mailing Address - Fax:
Practice Address - Street 1:2525 PONCE DE LEON BLVD STE 300
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-6044
Practice Address - Country:US
Practice Address - Phone:786-571-4636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FLIMT3593106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst