Provider Demographics
NPI:1437662939
Name:CARLISLE, NICOYAH
Entity Type:Individual
Prefix:
First Name:NICOYAH
Middle Name:
Last Name:CARLISLE
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 1:2701 N ROCKY POINT DR STE 650
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-5999
Mailing Address - Country:US
Mailing Address - Phone:800-892-0640
Mailing Address - Fax:
Practice Address - Street 1:12966 SW 89TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-5850
Practice Address - Country:US
Practice Address - Phone:786-303-1733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL21928225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician