Provider Demographics
NPI:1760999437
Name:HERON, NICOLE
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:HERON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:KNOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2073 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3243
Mailing Address - Country:US
Mailing Address - Phone:321-888-3020
Mailing Address - Fax:661-263-4584
Practice Address - Street 1:7075 N HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32927-5216
Practice Address - Country:US
Practice Address - Phone:321-888-3020
Practice Address - Fax:661-263-4584
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-61394103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst