Provider Demographics
NPI:1245579069
Name:MONTANEZ, NICOLETTE (BCBA)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:MONTANEZ
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7505 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:TUJUNGA
Mailing Address - State:CA
Mailing Address - Zip Code:91042-2116
Mailing Address - Country:US
Mailing Address - Phone:818-353-3772
Mailing Address - Fax:
Practice Address - Street 1:7505 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:TUJUNGA
Practice Address - State:CA
Practice Address - Zip Code:91042-2116
Practice Address - Country:US
Practice Address - Phone:818-353-3772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-12-11751103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1-12-11751OtherBCBA CERTIFICATE NUMBER