Provider Demographics
NPI:1568046621
Name:WHEATON, HOLLAND NICOLE (MA, BCBA)
Entity type:Individual
Prefix:
First Name:HOLLAND
Middle Name:NICOLE
Last Name:WHEATON
Suffix:
Gender:
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:NICOLE
Other - Last Name:WHEATON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, BCBA
Mailing Address - Street 1:2008 173RD ST SE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-6466
Mailing Address - Country:US
Mailing Address - Phone:509-954-0422
Mailing Address - Fax:
Practice Address - Street 1:5452 CONGRESS AVE APT 1
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-2233
Practice Address - Country:US
Practice Address - Phone:509-954-0422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
1-25-79499103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician