Provider Demographics
NPI:1548765886
Name:JUDAH, NICOLE LAUREN (MED, BCBA)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:LAUREN
Last Name:JUDAH
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 HIDDEN ACRES LN
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:CA
Mailing Address - Zip Code:95658-9617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1083 FOXFIRE DR
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-6695
Practice Address - Country:US
Practice Address - Phone:209-739-0349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-17-29919103K00000X
CA1-18-29919103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst