Provider Demographics
NPI:1811539497
Name:PERITO, NICOLE (LBS, BCBA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PERITO
Suffix:
Gender:F
Credentials:LBS, BCBA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:KOVAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:120 E LAKE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:DINGMANS FERRY
Mailing Address - State:PA
Mailing Address - Zip Code:18328-9135
Mailing Address - Country:US
Mailing Address - Phone:845-943-0035
Mailing Address - Fax:
Practice Address - Street 1:175 E BROWN ST STE 202
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3098
Practice Address - Country:US
Practice Address - Phone:570-234-3989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-19-37109103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst