Provider Demographics
NPI:1629664446
Name:GIBSON, NICOLE LYNN (BCBA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 LINDA LN
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-8035
Mailing Address - Country:US
Mailing Address - Phone:304-690-6428
Mailing Address - Fax:
Practice Address - Street 1:217 LINDA LN
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-8035
Practice Address - Country:US
Practice Address - Phone:304-690-6428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY246629103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst