Provider Demographics
NPI:1962097170
Name:HOUSEHOLDER, NICOLE LEANN (RBT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEANN
Last Name:HOUSEHOLDER
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LEANN
Other - Last Name:DEVLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6810 FORT JACKSON CT
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-7692
Mailing Address - Country:US
Mailing Address - Phone:850-503-6636
Mailing Address - Fax:850-626-6132
Practice Address - Street 1:6810 FORT JACKSON CT
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-7692
Practice Address - Country:US
Practice Address - Phone:850-503-6636
Practice Address - Fax:850-626-6132
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-21-159268106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician