Provider Demographics
NPI:1164712758
Name:TISDALE, NICOLE JUSTINE (MS, BCBA)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:JUSTINE
Last Name:TISDALE
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:25600 CROSS CREEK DR
Mailing Address - Street 2:49C
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92887-6238
Mailing Address - Country:US
Mailing Address - Phone:714-497-5543
Mailing Address - Fax:
Practice Address - Street 1:25600 CROSS CREEK DR
Practice Address - Street 2:49C
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92887-6238
Practice Address - Country:US
Practice Address - Phone:714-497-5543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-09-5703103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst