Provider Demographics
NPI:1982103305
Name:IVORY, NICOLE EILEEN (MED, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:EILEEN
Last Name:IVORY
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 MADISON RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-1428
Mailing Address - Country:US
Mailing Address - Phone:513-861-0300
Mailing Address - Fax:513-861-0213
Practice Address - Street 1:4850 MADISON RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45227-1428
Practice Address - Country:US
Practice Address - Phone:513-861-0300
Practice Address - Fax:513-861-0213
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-17-26624103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0007242Medicaid