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NPI Code Detail

MEDICARE: NICOLETTE LYNN GOINES BCBA

MEDICARE: NICOLETTE LYNN GOINES BCBA
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
1103K00000XBehavior Analyst11166867-2506UT
2247200000XOther Technician

General Provider Information

NPI Number : 1295129039
Entity Type Code : Individual
Provider Name (Legal Business Name) : NICOLETTE LYNN GOINES BCBA
Provider Business Mailing Address
First Line : 7901 S CARLY CT
Second Line :
City : WEST JORDAN
State : UT
Zip : 84088-4666
Country : US
Telephone Number : 801-516-8104
Fax Number :
Provider Business Practice Location Address
First Line : 240 MORRIS AVE STE 400
Second Line :
City : SOUTH SALT LAKE
State : UT
Zip : 84115-3295
Country : US
Telephone Number : 801-587-8020
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/18/2015
Last Update Date : 04/27/2022

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