Provider Demographics
NPI:1699091363
Name:SUCHOMEL, NICOLE G (MS, BCBA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:G
Last Name:SUCHOMEL
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 1:5353 KELLER SPRINGS RD
Mailing Address - Street 2:1223
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-2778
Mailing Address - Country:US
Mailing Address - Phone:715-271-2442
Mailing Address - Fax:
Practice Address - Street 1:21007 E. AVENDIA DEL VALLE
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85242
Practice Address - Country:US
Practice Address - Phone:480-361-1025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-09-6593103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst