Healthcare Provider Details

I. General information

NPI: 1134616329
Provider Name (Legal Business Name): NICOLE GARDNER BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 04/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FRANKLIN SQUARE DR STE 205
SOMERSET NJ
08873-4109
US

IV. Provider business mailing address

145 PARK AVE
KEANSBURG NJ
07734-1842
US

V. Phone/Fax

Practice location:
  • Phone: 908-917-2552
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: