Provider Demographics
NPI:1912446238
Name:WAITT, NICOLE ELIZABETH (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:WAITT
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:NIKKI
Other - Middle Name:
Other - Last Name:WAITT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1565 HIGHWAY 34 E
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2401
Practice Address - Country:US
Practice Address - Phone:877-288-4760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-20
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-45580103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst