Provider Demographics
NPI:1073123998
Name:NUTKIS, IAN JAMES (BCBA)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:JAMES
Last Name:NUTKIS
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-7603
Mailing Address - Country:US
Mailing Address - Phone:973-919-4503
Mailing Address - Fax:
Practice Address - Street 1:329 AYCRIGG AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-3713
Practice Address - Country:US
Practice Address - Phone:973-471-3046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1-12-10205OtherBACB