Provider Demographics
NPI:1225440662
Name:NOVIKOVA, NIKOLE
Entity Type:Individual
Prefix:
First Name:NIKOLE
Middle Name:
Last Name:NOVIKOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4628 S CENTRIC WAY
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-9417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10005 E OSBORN RD BLDG 61
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85256-4019
Practice Address - Country:US
Practice Address - Phone:480-946-9066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60460804103K00000X
AZD011130122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst