Provider Demographics
NPI:1871199778
Name:ZIMMERLY, NICOLE (RBT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ZIMMERLY
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32395 CLINTON KEITH RD STE B12
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-7568
Mailing Address - Country:US
Mailing Address - Phone:951-200-5532
Mailing Address - Fax:
Practice Address - Street 1:32395 CLINTON KEITH RD STE B12
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-7568
Practice Address - Country:US
Practice Address - Phone:951-200-5532
Practice Address - Fax:951-719-3429
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-20-145325106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician