Provider Demographics
NPI:1932809811
Name:HARMAN, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HARMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:751 S UNIVERSITY AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-3368
Mailing Address - Country:US
Mailing Address - Phone:208-241-3386
Mailing Address - Fax:
Practice Address - Street 1:240 E MAPLE ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4647
Practice Address - Country:US
Practice Address - Phone:208-226-4785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician