Basic Information
| Provider Information | |||||||||
| NPI: | 1114393030 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICKERSON | ||||||||
| FirstName: | CICELY | ||||||||
| MiddleName: | IRENE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13923 S HAYSTACK PEAK CIR | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840966453 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 13923 S HAYSTACK PEAK CIR | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840966453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015066695 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2015 | ||||||||
| LastUpdateDate: | 08/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.