Provider Demographics
NPI:1649880493
Name:NICHOLS, SHANE (BCBA)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:NICHOLS
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 1:1401 APPLEWOOD DR STE 2
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2699
Mailing Address - Country:US
Mailing Address - Phone:706-250-9372
Mailing Address - Fax:706-343-9939
Practice Address - Street 1:1401 APPLEWOOD DR STE 2
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2699
Practice Address - Country:US
Practice Address - Phone:706-250-9372
Practice Address - Fax:706-343-9939
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-20-42979103K00000X
WY1-20-42979103K00000X
GA1-20-42979103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst