Provider Demographics
NPI:1740994821
Name:SMITH, NICHOLETTE JULIA
Entity type:Individual
Prefix:
First Name:NICHOLETTE
Middle Name:JULIA
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICHOLETTE
Other - Middle Name:JULIA
Other - Last Name:FREDRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1585 CENTRAL PARK DR APT 2
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-3631
Mailing Address - Country:US
Mailing Address - Phone:616-821-0840
Mailing Address - Fax:
Practice Address - Street 1:1585 CENTRAL PARK DR APT 2
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-3631
Practice Address - Country:US
Practice Address - Phone:616-821-0840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherI DONT HAVE A PROVIDER.