Provider Demographics
NPI:1326845090
Name:WIDENER, NICOLE (RBT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WIDENER
Suffix:
Gender:
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064-1202
Mailing Address - Country:US
Mailing Address - Phone:765-623-6843
Mailing Address - Fax:
Practice Address - Street 1:5719 S MADISON AVE
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-1651
Practice Address - Country:US
Practice Address - Phone:765-617-2279
Practice Address - Fax:765-274-5244
Is Sole Proprietor?:No
Enumeration Date:2025-02-28
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-22-211431106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician