MEDICARE: MRS. NICOLE SHANNON HERRERA BCABA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	0-11-4012	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0-11-4012	OTHER	CO	BCABA CERIFICATION NUMBER (BOARD CERTIFIED ASSISTANT BEHAVIOR ANALYST)

General Provider Information

NPI Number	:	1093005001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLE SHANNON HERRERA BCABA

Provider Business Mailing Address
First Line	:	8319 NEWBURY WAY
Second Line	:
City	:	FOUNTAIN
State	:	CO
Zip	:	80817-4049
Country	:	US
Telephone Number	:	850-630-3358
Fax Number	:

Provider Business Practice Location Address
First Line	:	8319 NEWBURY WAY
Second Line	:
City	:	FOUNTAIN
State	:	CO
Zip	:	80817-4049
Country	:	US
Telephone Number	:	850-630-3358
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2011
Last Update Date	:	04/11/2011

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