Healthcare Provider Details

I. General information

NPI: 1568046621
Provider Name (Legal Business Name): HOLLAND NICOLE WHEATON MA, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HOLLY NICOLE WHEATON MA, BCBA

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5452 CONGRESS AVE APT 1
MADISON WI
53718-2233
US

IV. Provider business mailing address

2008 173RD ST SE
BOTHELL WA
98012-6466
US

V. Phone/Fax

Practice location:
  • Phone: 509-954-0422
  • Fax:
Mailing address:
  • Phone: 509-954-0422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-79499
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: