1023504586 NPI number — MRS. NIKOLE DONELON MCCOY BCBA

Table of content: MRS. NIKOLE DONELON MCCOY BCBA (NPI 1023504586)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023504586 NPI number — MRS. NIKOLE DONELON MCCOY BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCOY
Provider First Name:
NIKOLE
Provider Middle Name:
DONELON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIMENSMA
Provider Other First Name:
NIKOLE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
BCBA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023504586
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4839 PIMENTA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90712-3520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-688-1487
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
713 W COMMONWEALTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FULLERTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92832-1612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-879-4274
Provider Business Practice Location Address Fax Number:
714-879-2274
Provider Enumeration Date:
07/09/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-18-31039 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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