Provider Demographics
NPI:1861261315
Name:REBUSTILLO PUIG, NICOLE MICHELLE (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
Last Name:REBUSTILLO PUIG
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 1:11740 NW 39TH PL
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-3626
Mailing Address - Country:US
Mailing Address - Phone:786-518-8830
Mailing Address - Fax:
Practice Address - Street 1:11740 NW 39TH PL
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-3626
Practice Address - Country:US
Practice Address - Phone:786-518-8830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical