Basic Information
| Provider Information | |||||||||
| NPI: | 1528360310 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | NICHOLE | ||||||||
| MiddleName: | BROOKE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.A., BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 164 LAKE FRONT DR | ||||||||
| Address2: | |||||||||
| City: | COCKEYSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210302215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107853845 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 164 LAKE FRONT DR | ||||||||
| Address2: | |||||||||
| City: | COCKEYSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210302215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107853845 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2010 | ||||||||
| LastUpdateDate: | 11/30/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-10-7833 | MD | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 743078488 | 01 | MD | DO NOT TAKE MEDICARE | OTHER |