Provider Demographics
NPI:1417463431
Name:SMITH, NICOLE M (RBT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4681 35TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-3540
Mailing Address - Country:US
Mailing Address - Phone:215-873-7093
Mailing Address - Fax:
Practice Address - Street 1:3978 SORRENTO VALLEY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1436
Practice Address - Country:US
Practice Address - Phone:858-428-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-16-12732106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician