Healthcare Provider Details

I. General information

NPI: 1336657774
Provider Name (Legal Business Name): NICOLE RENAE RICKS MS, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE RENAE MANUEL BS, RBT, BCAT

II. Dates (important events)

Enumeration Date: 01/19/2018
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

378 MT BROSS AVE
SEVERANCE CO
80550-4862
US

IV. Provider business mailing address

3621 MARION LN
LAS CRUCES NM
88012-7579
US

V. Phone/Fax

Practice location:
  • Phone: 171-933-9836
  • Fax:
Mailing address:
  • Phone: 647-828-4133
  • Fax: 505-929-6200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number103550741
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-49506
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: