Provider Demographics
NPI:1295129039
Name:GOINES, NICOLETTE LYNN (BCBA)
Entity type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:LYNN
Last Name:GOINES
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 S CARLY CT
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-4666
Mailing Address - Country:US
Mailing Address - Phone:801-516-8104
Mailing Address - Fax:
Practice Address - Street 1:240 MORRIS AVE STE 400
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-3295
Practice Address - Country:US
Practice Address - Phone:801-587-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11166867-2506103K00000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other