Provider Demographics
NPI:1336657774
Name:RICKS, NICOLE RENAE (MS, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:RENAE
Last Name:RICKS
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:RENAE
Other - Last Name:MANUEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS, RBT, BCAT
Mailing Address - Street 1:3621 MARION LN
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-7579
Mailing Address - Country:US
Mailing Address - Phone:647-828-4133
Mailing Address - Fax:505-929-6200
Practice Address - Street 1:378 MT BROSS AVE
Practice Address - Street 2:
Practice Address - City:SEVERANCE
Practice Address - State:CO
Practice Address - Zip Code:80550-4862
Practice Address - Country:US
Practice Address - Phone:171-933-9836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO103550741106S00000X
CO1-21-49506103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21782369Medicaid