Provider Demographics
NPI:1326625823
Name:MCDONALD, NICOLE RAE (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAE
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:POSITIE CHANGE ABA
Other - Middle Name:
Other - Last Name:LLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:436 TUMBLEWEED PASS
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-8541
Mailing Address - Country:US
Mailing Address - Phone:417-894-1231
Mailing Address - Fax:
Practice Address - Street 1:436 TUMBLEWEED PASS
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-8541
Practice Address - Country:US
Practice Address - Phone:417-894-1231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1-21-48606103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty