Provider Demographics
NPI:1881735819
Name:WOLLER, NICOLE (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:WOLLER
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2735 SE 140TH PL
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-2877
Mailing Address - Country:US
Mailing Address - Phone:561-715-5910
Mailing Address - Fax:561-892-0268
Practice Address - Street 1:5818 SE AGNEW RD
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420-4020
Practice Address - Country:US
Practice Address - Phone:561-706-1004
Practice Address - Fax:561-892-0268
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 103TB0200X, 103TF0200X
FLSW85531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11758162OtherCAQH
FL767023100Medicaid