Provider Demographics
NPI:1366047847
Name:MIXDORF, NICOLE DIANE (BCBA)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:DIANE
Last Name:MIXDORF
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 N MOBILE VILLA DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-6500
Mailing Address - Country:US
Mailing Address - Phone:850-896-6925
Mailing Address - Fax:
Practice Address - Street 1:30250 SOUTHWELL LN
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-5926
Practice Address - Country:US
Practice Address - Phone:134-709-5668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-146743106S00000X
FL1-25-81550103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician