Provider Demographics
NPI:1285480533
Name:BOUCICAULT, NANCY
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:BOUCICAULT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:FLEURIVAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:736 WARWICK ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-7448
Mailing Address - Country:US
Mailing Address - Phone:347-383-1509
Mailing Address - Fax:
Practice Address - Street 1:11333 204TH ST FL 1
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-2534
Practice Address - Country:US
Practice Address - Phone:347-383-1509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-27
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst