Provider Demographics
NPI:1033514740
Name:REILLY, NICHOLE (BCBA)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5762 BOLSA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-1172
Mailing Address - Country:US
Mailing Address - Phone:714-292-2322
Mailing Address - Fax:714-866-4153
Practice Address - Street 1:5762 BOLSA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-1172
Practice Address - Country:US
Practice Address - Phone:714-292-2322
Practice Address - Fax:714-866-4153
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-10381103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst