Provider Demographics
NPI:1790546737
Name:SURRAN, NICOLE ANDROMEDA (R-DMT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANDROMEDA
Last Name:SURRAN
Suffix:
Gender:F
Credentials:R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 N TUCSON BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-3074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 N TUCSON BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-3074
Practice Address - Country:US
Practice Address - Phone:520-372-2672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2895225600000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist