Provider Demographics
NPI:1558497719
Name:VREDENBURG, NICOLE LYNN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LYNN
Last Name:VREDENBURG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 W. BROWARD BLVD.
Mailing Address - Street 2:SUITE 800
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317
Mailing Address - Country:US
Mailing Address - Phone:954-854-6533
Mailing Address - Fax:
Practice Address - Street 1:4302 W BROWARD BLVD
Practice Address - Street 2:SUITE 800
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-3780
Practice Address - Country:US
Practice Address - Phone:954-854-6533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW93721041C0700X
253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767163600Medicaid