Provider Demographics
NPI:1164915922
Name:NICHOLSON, ANNA L (RBT)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:L
Last Name:NICHOLSON
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 1:800 W WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-2472
Mailing Address - Country:US
Mailing Address - Phone:502-409-7181
Mailing Address - Fax:888-450-0935
Practice Address - Street 1:800 W WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215
Practice Address - Country:US
Practice Address - Phone:502-409-7181
Practice Address - Fax:888-450-0935
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-17-39054106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician