Provider Demographics
NPI:1780294512
Name:NISSLEY, COURTNEY KATHLEEN (MED, BCBA, LBS)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:KATHLEEN
Last Name:NISSLEY
Suffix:
Gender:F
Credentials:MED, BCBA, LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT JOY
Mailing Address - State:PA
Mailing Address - Zip Code:17552-9018
Mailing Address - Country:US
Mailing Address - Phone:717-203-2445
Mailing Address - Fax:
Practice Address - Street 1:7540 ALLENTOWN BLVD STE 5
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17112-4238
Practice Address - Country:US
Practice Address - Phone:717-649-6085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH005034103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst