Provider Demographics
NPI:1316171804
Name:CLEARY, NICOLE ANN (MS, BCBA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:CLEARY
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 OPEN POND RD
Mailing Address - Street 2:
Mailing Address - City:SAMSON
Mailing Address - State:AL
Mailing Address - Zip Code:36477-7750
Mailing Address - Country:US
Mailing Address - Phone:850-258-0590
Mailing Address - Fax:
Practice Address - Street 1:1501 HONEYSUCKLE RD STE 2
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1967
Practice Address - Country:US
Practice Address - Phone:334-671-1650
Practice Address - Fax:334-671-1659
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-06-2863103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst