Provider Demographics
NPI:1952424491
Name:NICOLOSI, DEBRA E
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:E
Last Name:NICOLOSI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14928 BONAIRE CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-1898
Mailing Address - Country:US
Mailing Address - Phone:239-223-4595
Mailing Address - Fax:
Practice Address - Street 1:8961 DANIELS CENTER DR STE 401
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-0314
Practice Address - Country:US
Practice Address - Phone:239-223-4595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLITDS222Q00000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist