Provider Demographics
NPI:1356602650
Name:DAVIS, NICOLE D (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:D
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 NORTHDALE BLVD
Mailing Address - Street 2:SUITE 312B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1863
Mailing Address - Country:US
Mailing Address - Phone:813-968-3417
Mailing Address - Fax:813-968-5051
Practice Address - Street 1:3820 NORTHDALE BLVD
Practice Address - Street 2:SUITE 312B
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-1863
Practice Address - Country:US
Practice Address - Phone:813-968-3417
Practice Address - Fax:813-968-5051
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW105551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical