Provider Demographics
NPI:1528360310
Name:STEWART, NICHOLE BROOKE (BA, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:BROOKE
Last Name:STEWART
Suffix:
Gender:F
Credentials:BA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 LAKE FRONT DR
Mailing Address - Street 2:
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-2215
Mailing Address - Country:US
Mailing Address - Phone:410-785-3845
Mailing Address - Fax:
Practice Address - Street 1:164 LAKE FRONT DR
Practice Address - Street 2:
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030-2215
Practice Address - Country:US
Practice Address - Phone:410-785-3845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1-10-7833103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD743078488OtherDO NOT TAKE MEDICARE