Provider Demographics
NPI:1609474766
Name:BAKEWELL, NICOLE CHRISTINE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CHRISTINE
Last Name:BAKEWELL
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 1:6040 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-3214
Mailing Address - Country:US
Mailing Address - Phone:727-841-4475
Mailing Address - Fax:727-841-4478
Practice Address - Street 1:6040 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-3214
Practice Address - Country:US
Practice Address - Phone:727-841-4475
Practice Address - Fax:727-841-4478
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH15590101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health