Provider Demographics
NPI:1043852312
Name:PRINCE, NICOLE GRACE (RBT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:GRACE
Last Name:PRINCE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5954 HALEOLA ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96821-2141
Mailing Address - Country:US
Mailing Address - Phone:808-295-9043
Mailing Address - Fax:
Practice Address - Street 1:5954 HALEOLA ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96821-2141
Practice Address - Country:US
Practice Address - Phone:808-295-9043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI23-313553106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician