Provider Demographics
NPI:1558649772
Name:FETHIERE, NIKOLE (MED, EDS, LMHC)
Entity Type:Individual
Prefix:
First Name:NIKOLE
Middle Name:
Last Name:FETHIERE
Suffix:
Gender:F
Credentials:MED, EDS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3463 NW 13TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32609-2172
Mailing Address - Country:US
Mailing Address - Phone:305-498-0125
Mailing Address - Fax:
Practice Address - Street 1:3463 NW 13TH ST STE C
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-2172
Practice Address - Country:US
Practice Address - Phone:305-498-0125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-22
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13730101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL13730OtherSTATE MH LICENSE
FL016249000Medicaid