Provider Demographics
NPI:1568176923
Name:CORREA, NELLY
Entity Type:Individual
Prefix:
First Name:NELLY
Middle Name:
Last Name:CORREA
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 1:2502 N DIXIE HWY UNIT 4
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-6270
Mailing Address - Country:US
Mailing Address - Phone:561-502-5745
Mailing Address - Fax:
Practice Address - Street 1:515 N FLAGLER DR STE P300
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-4326
Practice Address - Country:US
Practice Address - Phone:561-722-9107
Practice Address - Fax:561-448-6063
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-23-252265106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician