Provider Demographics
NPI:1134378003
Name:GROSKREUTZ, NICOLE CHRISTINE (MSED, BCBA)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:CHRISTINE
Last Name:GROSKREUTZ
Suffix:
Gender:F
Credentials:MSED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 ROCKWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9477
Mailing Address - Country:US
Mailing Address - Phone:508-423-1007
Mailing Address - Fax:
Practice Address - Street 1:521 ROCKWOOD CIR
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9477
Practice Address - Country:US
Practice Address - Phone:508-423-1007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-05-2248103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral