Provider Demographics
NPI:1093330763
Name:LANDRY, NICOLE VIVIAN (BCBA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:VIVIAN
Last Name:LANDRY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 JOHNSON AVE N
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-3519
Mailing Address - Country:US
Mailing Address - Phone:631-316-5870
Mailing Address - Fax:
Practice Address - Street 1:229 LAUREL RD
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-1118
Practice Address - Country:US
Practice Address - Phone:631-659-3337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst