Provider Demographics
NPI:1073063798
Name:SHEPHERD, NICOLE (RBT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SHEPHERD
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 1:235 W CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84029-9648
Mailing Address - Country:US
Mailing Address - Phone:435-901-8545
Mailing Address - Fax:
Practice Address - Street 1:2985 N 935 E
Practice Address - Street 2:SUITE 7
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84040-7308
Practice Address - Country:US
Practice Address - Phone:801-771-0273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-16-24413106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician