Provider Demographics
NPI:1093590275
Name:NICHOLAS, GRACE (RBT)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-2719
Mailing Address - Country:US
Mailing Address - Phone:979-900-8194
Mailing Address - Fax:
Practice Address - Street 1:1351 SPRINKLE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5448
Practice Address - Country:US
Practice Address - Phone:979-900-8194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-293916106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician