Provider Demographics
NPI:1467835132
Name:NEBORAK, NICHOLAS ALEXANDER (RCSWI)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ALEXANDER
Last Name:NEBORAK
Suffix:
Gender:M
Credentials:RCSWI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1975 S JOHN YOUNG PKWY
Mailing Address - Street 2:SUITE 203A
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-0603
Mailing Address - Country:US
Mailing Address - Phone:321-236-1540
Mailing Address - Fax:
Practice Address - Street 1:1975 S JOHN YOUNG PKWY
Practice Address - Street 2:SUITE 203A
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-0603
Practice Address - Country:US
Practice Address - Phone:321-236-1540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW 9811104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker