Provider Demographics
NPI:1750855912
Name:THOMAS, NICOLE L (BCBA)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:L
Last Name:THOMAS
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 1:7627 ISLAND CLUB DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-4159
Mailing Address - Country:US
Mailing Address - Phone:219-718-1909
Mailing Address - Fax:
Practice Address - Street 1:8350 CRAIG ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-3593
Practice Address - Country:US
Practice Address - Phone:317-578-0410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-18-33768103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
INH0032OtherUMR
INH0032OtherIU HEALTH
INH0032OtherUHC
IN97155OtherMHS
IN96151Medicaid
IN97155OtherCARE SOURCE
IN97155OtherAETNA