Provider Demographics
NPI:1629483698
Name:AGRESTO, NICOLE (PSYD,)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:AGRESTO
Suffix:
Gender:F
Credentials:PSYD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 49TH ST N STE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-5237
Mailing Address - Country:US
Mailing Address - Phone:727-685-0934
Mailing Address - Fax:727-279-4986
Practice Address - Street 1:2150 49TH ST N STE E
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5237
Practice Address - Country:US
Practice Address - Phone:727-685-0934
Practice Address - Fax:727-279-4986
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-27
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9016103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical