Provider Demographics
NPI:1083172209
Name:NICOLLE, HEATHER (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:NICOLLE
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 2ND ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BEACH
Mailing Address - State:MD
Mailing Address - Zip Code:20714-9733
Mailing Address - Country:US
Mailing Address - Phone:443-366-5971
Mailing Address - Fax:
Practice Address - Street 1:2412 COMPTROLLERS CT
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4340
Practice Address - Country:US
Practice Address - Phone:443-295-3015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLBA1152103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst