=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780128801
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE GRILLE BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2016
-----------------------------------------------------
Last Update Date | 05/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8160 GENEVA CT APT 311
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-4659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-925-7633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9711 HAMMOCKS BLVD APT 101
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33196-1555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-537-1583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------