Provider Demographics
NPI:1871020339
Name:STEWART, NICOLE (MSED, BCBA, LBA-NY)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:MSED, BCBA, LBA-NY
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:HERZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 OAKVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-2214
Mailing Address - Country:US
Mailing Address - Phone:973-809-3543
Mailing Address - Fax:
Practice Address - Street 1:20 OAKVIEW AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-2214
Practice Address - Country:US
Practice Address - Phone:973-809-3543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-16
Last Update Date:2021-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000650103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000650OtherLBA
1-12-10434OtherBCBA