Provider Demographics
NPI:1831704667
Name:CHACHO, NICOLE (MA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CHACHO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N MAITLAND AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4440
Mailing Address - Country:US
Mailing Address - Phone:407-628-5354
Mailing Address - Fax:
Practice Address - Street 1:500 N MAITLAND AVE STE 110
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4440
Practice Address - Country:US
Practice Address - Phone:407-628-5354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20070101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIMH20070OtherSTATE OF FLORIDA DEPARTMENT OF HEALTH