MEDICARE: NICOLE GOODMAN M.S., BCBA, LBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician
2	103K00000X	Behavior Analyst	7401001950	MI

General Provider Information

NPI Number	:	1174120042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE GOODMAN M.S., BCBA, LBA

Provider Business Mailing Address
First Line	:	2248 MOUNT HOPE RD
Second Line	:
City	:	OKEMOS
State	:	MI
Zip	:	48864-2501
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2248 MOUNT HOPE RD
Second Line	:
City	:	OKEMOS
State	:	MI
Zip	:	48864-2501
Country	:	US
Telephone Number	:	517-604-8855
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2020
Last Update Date	:	06/05/2026

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Directions to “ NICOLE GOODMAN M.S., BCBA, LBA” Practice Location

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