Provider Demographics
NPI:1508364019
Name:PHILLIPS, NICOLE (BCBA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PHILLIPS
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 1:8053 W OAKLAND PARK BLVD STE 950
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-1162
Mailing Address - Country:US
Mailing Address - Phone:754-422-2165
Mailing Address - Fax:
Practice Address - Street 1:8053 WEST OAKLAND PARK BLVD
Practice Address - Street 2:SUITE 950
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-7776
Practice Address - Country:US
Practice Address - Phone:754-422-2165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2022-11-28
Deactivation Date:2018-01-30
Deactivation Code:
Reactivation Date:2020-09-09
Provider Licenses
StateLicense IDTaxonomies
FL12044065103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst