Provider Demographics
NPI:1801315502
Name:NICOLAS, METUSHELA
Entity type:Individual
Prefix:
First Name:METUSHELA
Middle Name:
Last Name:NICOLAS
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 1:8 WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:POINCIANA
Mailing Address - State:FL
Mailing Address - Zip Code:34759-5578
Mailing Address - Country:US
Mailing Address - Phone:561-839-0696
Mailing Address - Fax:
Practice Address - Street 1:8 WILLOW LN
Practice Address - Street 2:
Practice Address - City:POINCIANA
Practice Address - State:FL
Practice Address - Zip Code:34759-5578
Practice Address - Country:US
Practice Address - Phone:561-839-0696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 1041C0700X, 1041S0200X, 372600000X, 376J00000X, 106S00000X
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker