Provider Demographics
NPI:1013749845
Name:NASH, NATHANAEL JACOB ISAIAH (RBT, RLT)
Entity type:Individual
Prefix:MR
First Name:NATHANAEL
Middle Name:JACOB ISAIAH
Last Name:NASH
Suffix:
Gender:M
Credentials:RBT, RLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6722 COIT ST APT A
Mailing Address - Street 2:
Mailing Address - City:FORT JOHNSON
Mailing Address - State:LA
Mailing Address - Zip Code:71459-3216
Mailing Address - Country:US
Mailing Address - Phone:909-782-8359
Mailing Address - Fax:
Practice Address - Street 1:422 VFW RD
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-6302
Practice Address - Country:US
Practice Address - Phone:917-526-2384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAR-19463106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician