Provider Demographics
NPI:1316817554
Name:KING, NICKOLE MARIE
Entity type:Individual
Prefix:
First Name:NICKOLE
Middle Name:MARIE
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BUDDY DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-7002
Mailing Address - Country:US
Mailing Address - Phone:661-619-8145
Mailing Address - Fax:
Practice Address - Street 1:209 CENTRE SARCELLE BLVD
Practice Address - Street 2:
Practice Address - City:YOUNGSVILLE
Practice Address - State:LA
Practice Address - Zip Code:70592-6755
Practice Address - Country:US
Practice Address - Phone:661-619-8145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-11
Last Update Date:2025-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician