Provider Demographics
NPI:1629856307
Name:CLERVIL, NICKKI-SHELLY
Entity Type:Individual
Prefix:
First Name:NICKKI-SHELLY
Middle Name:
Last Name:CLERVIL
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 1:17600 NE 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-2004
Mailing Address - Country:US
Mailing Address - Phone:305-796-4348
Mailing Address - Fax:
Practice Address - Street 1:17121 NE 6TH AVE
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-2008
Practice Address - Country:US
Practice Address - Phone:786-955-6224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB983547106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician