Provider Demographics
NPI:1710484258
Name:DE LA TORRE SALAS, NICOLE MARIE (MS)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:MARIE
Last Name:DE LA TORRE SALAS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 ARORA BLVD APT 205
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-3232
Mailing Address - Country:US
Mailing Address - Phone:787-219-7393
Mailing Address - Fax:
Practice Address - Street 1:4595 LEXINGTON AVE FL 32210
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-2058
Practice Address - Country:US
Practice Address - Phone:904-448-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23301101YM0800X
FLIMH17069101YM0800X
FLMH23301101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health