Provider Demographics
NPI:1558936195
Name:THOMPSON, NICOLE (RBT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:THOMPSON
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 1:3858 WESTVIEW AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-2425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6657 FRANK AVE NW STE 100
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-8438
Practice Address - Country:US
Practice Address - Phone:330-309-3133
Practice Address - Fax:877-319-8460
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRBT-21-156351106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician