Provider Demographics
NPI:1568766525
Name:MINARD, NICOLE MCLEAN (MA, BCBA)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:MCLEAN
Last Name:MINARD
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1284 DEVIN OAKS CT
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33811-2383
Mailing Address - Country:US
Mailing Address - Phone:863-602-0698
Mailing Address - Fax:813-354-2715
Practice Address - Street 1:1284 DEVIN OAKS CT
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33811-2383
Practice Address - Country:US
Practice Address - Phone:863-602-0698
Practice Address - Fax:813-354-2715
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-05
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018166700Medicaid