Healthcare Provider Details

I. General information

NPI: 1043125917
Provider Name (Legal Business Name): BRIELLE J NICHOLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 S UNIVERSITY DR STE 502
DAVIE FL
33328-5313
US

IV. Provider business mailing address

19 FLORENCE AVE
WEST HAVEN CT
06516-7946
US

V. Phone/Fax

Practice location:
  • Phone: 203-519-9044
  • Fax:
Mailing address:
  • Phone: 203-519-9044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: