Provider Demographics
NPI:1942959812
Name:HERTRICH, NICOLE MICHELLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
Last Name:HERTRICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10823 SW 142ND CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-3056
Mailing Address - Country:US
Mailing Address - Phone:305-926-6250
Mailing Address - Fax:
Practice Address - Street 1:4964 N PALM AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-9111
Practice Address - Country:US
Practice Address - Phone:321-228-3765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-19
Last Update Date:2022-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-173340106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician