Provider Demographics
NPI:1578854105
Name:MATTHEWS, NICOLE HAZELTON (MED, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:HAZELTON
Last Name:MATTHEWS
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 1:7434 SOUTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047
Mailing Address - Country:US
Mailing Address - Phone:801-456-9955
Mailing Address - Fax:801-456-9954
Practice Address - Street 1:7434 S. STATE ST.
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047
Practice Address - Country:US
Practice Address - Phone:801-456-9955
Practice Address - Fax:801-456-9954
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-01
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-11-8121103K00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst