Healthcare Provider Details

I. General information

NPI: 1306438403
Provider Name (Legal Business Name): MISS NICOLE ERIN PIQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 MIDWAY DR UNIT 371141
SAN DIEGO CA
92110
US

IV. Provider business mailing address

2758 ARIANE DR UNIT 126
SAN DIEGO CA
92117-3412
US

V. Phone/Fax

Practice location:
  • Phone: 904-638-6388
  • Fax:
Mailing address:
  • Phone: 214-797-7559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number9627
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number25-0940-593100
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: