Provider Demographics
NPI:1942796735
Name:THOMAS, NIKITA
Entity Type:Individual
Prefix:
First Name:NIKITA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10175 FORTUNE PKWY UNIT 903
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6755
Mailing Address - Country:US
Mailing Address - Phone:904-538-0713
Mailing Address - Fax:904-538-0714
Practice Address - Street 1:1450 54TH ST STE C
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-4494
Practice Address - Country:US
Practice Address - Phone:706-221-1208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-18-59888106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician