Provider Demographics
NPI:1366047847
Name:MIXDORF, NICOLE DIANE (DSP-RBT)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:DIANE
Last Name:MIXDORF
Suffix:
Gender:F
Credentials:DSP-RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 N MOBILE VILLA DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-6500
Mailing Address - Country:US
Mailing Address - Phone:850-896-6925
Mailing Address - Fax:
Practice Address - Street 1:103 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-4619
Practice Address - Country:US
Practice Address - Phone:850-896-6925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-146743106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician