Provider Demographics
NPI:1932672441
Name:NICKERSON, MICHAEL W (BCBA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 DAVENPORT AVE
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:FL
Mailing Address - Zip Code:32580-1074
Mailing Address - Country:US
Mailing Address - Phone:850-974-5938
Mailing Address - Fax:
Practice Address - Street 1:415 DAVENPORT AVE
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:FL
Practice Address - Zip Code:32580-1074
Practice Address - Country:US
Practice Address - Phone:850-974-5938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1932672441Medicaid