Healthcare Provider Details

I. General information

NPI: 1437697083
Provider Name (Legal Business Name): NICOLE GRIFFIN LIPOWSKI BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MORGAN NICOLE GRIFFIN BCBA

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 05/28/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 JOE KENNEDY BLVD STE 13
STATESBORO GA
30458-3113
US

IV. Provider business mailing address

8223 W 141ST ST
ORLAND PARK IL
60462-2323
US

V. Phone/Fax

Practice location:
  • Phone: 912-208-2024
  • Fax:
Mailing address:
  • Phone: 912-690-5735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number051073736
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License NumberMG50380121P
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-36585
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: