Healthcare Provider Details

I. General information

NPI: 1861058331
Provider Name (Legal Business Name): CICELY NICHOLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2019
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7938 COLLEGE RD
BAXTER MN
56425-8636
US

IV. Provider business mailing address

149 CHATHAM RD
HAVELOCK NC
28532-3700
US

V. Phone/Fax

Practice location:
  • Phone: 978-857-5121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-34437
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: