Provider Demographics
NPI:1093493124
Name:NICHOLAS, CARLY P (BEHAVIOR TECHNICIAN)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:P
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:BEHAVIOR TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:756B S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-5061
Mailing Address - Country:US
Mailing Address - Phone:516-860-2159
Mailing Address - Fax:516-908-3526
Practice Address - Street 1:756B S BROADWAY
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-5061
Practice Address - Country:US
Practice Address - Phone:516-860-2159
Practice Address - Fax:516-908-3526
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22-239134106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician