Provider Demographics
NPI:1740771534
Name:SMOKER, NICOLE (BCBA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SMOKER
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 1:55 EMS T6 LN
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46538-9423
Mailing Address - Country:US
Mailing Address - Phone:574-387-4313
Mailing Address - Fax:574-204-2868
Practice Address - Street 1:55 EMS T6 LN
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:IN
Practice Address - Zip Code:46538-9423
Practice Address - Country:US
Practice Address - Phone:574-387-4313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-17-26586103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst