Provider Demographics
NPI:1104227727
Name:CARSON, NICOLE LYN (MA, BCBA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYN
Last Name:CARSON
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 MOTOR AVE # 101
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-4710
Mailing Address - Country:US
Mailing Address - Phone:818-577-3926
Mailing Address - Fax:
Practice Address - Street 1:3424 MOTOR AVE # 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-4710
Practice Address - Country:US
Practice Address - Phone:818-577-3926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst