Provider Demographics
NPI:1790171908
Name:AZEVEDO, NICOLE MONIQUE (BCBA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MONIQUE
Last Name:AZEVEDO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MONIQUE
Other - Last Name:RODRIGUES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:1377 COYOTE CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-7944
Mailing Address - Country:US
Mailing Address - Phone:408-728-5853
Mailing Address - Fax:
Practice Address - Street 1:1377 COYOTE CREEK WAY
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-7944
Practice Address - Country:US
Practice Address - Phone:408-728-5853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-14
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-15-18422103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst