Provider Demographics
NPI:1467711838
Name:NICKENS, DEBORAH LYNN (MS, LMHC)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:LYNN
Last Name:NICKENS
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 120729
Mailing Address - Street 2:
Mailing Address - City:W MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32912-0729
Mailing Address - Country:US
Mailing Address - Phone:321-506-4625
Mailing Address - Fax:321-723-8233
Practice Address - Street 1:810 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:W MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-7418
Practice Address - Country:US
Practice Address - Phone:321-506-4625
Practice Address - Fax:321-723-8233
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11221101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health