Provider Demographics
NPI:1093005001
Name:HERRERA, NICOLE SHANNON (BCABA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:SHANNON
Last Name:HERRERA
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8319 NEWBURY WAY
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-4049
Mailing Address - Country:US
Mailing Address - Phone:850-630-3358
Mailing Address - Fax:
Practice Address - Street 1:8319 NEWBURY WAY
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-4049
Practice Address - Country:US
Practice Address - Phone:850-630-3358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0-11-4012103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0-11-4012OtherBCABA CERIFICATION NUMBER (BOARD CERTIFIED ASSISTANT BEHAVIOR ANALYST)