Provider Demographics
NPI:1306404918
Name:STEPHENS, NICHELLE ANN (RBT)
Entity Type:Individual
Prefix:
First Name:NICHELLE
Middle Name:ANN
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:NICHELLE
Other - Middle Name:ANN
Other - Last Name:TANNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4872 W SERENGETI DR APT 503
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-7367
Mailing Address - Country:US
Mailing Address - Phone:315-921-1011
Mailing Address - Fax:
Practice Address - Street 1:5984 S SUSQUEHANNA
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84123-5527
Practice Address - Country:US
Practice Address - Phone:801-913-9963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst