Provider Demographics
NPI:1639648678
Name:NOLASCO, ALBA
Entity Type:Individual
Prefix:
First Name:ALBA
Middle Name:
Last Name:NOLASCO
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 1:2240 SW PORTSMOUTH LN
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-4366
Mailing Address - Country:US
Mailing Address - Phone:305-793-2682
Mailing Address - Fax:
Practice Address - Street 1:2240 SW PORTSMOUTH LN
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-4366
Practice Address - Country:US
Practice Address - Phone:305-793-2682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-71193106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician