Basic Information
Provider Information | |||||||||
NPI: | 1619270642 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CLARKSON | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: | STIEFLER | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | BCBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STIEFLER | ||||||||
OtherFirstName: | NICOLE | ||||||||
OtherMiddleName: | ALANA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | BCBA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 11820 CYPRESS CORNER LN | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770651132 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2818941423 | ||||||||
FaxNumber: | 2818941422 | ||||||||
Practice Location | |||||||||
Address1: | 11820 CYPRESS CORNER LN | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770651132 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2818941423 | ||||||||
FaxNumber: | 2818941422 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/14/2010 | ||||||||
LastUpdateDate: | 01/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-11-9667 |   | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
ID Information
ID | Type | State | Issuer | Description | 1741 | 01 | TX | LICENSED BCBA | OTHER | 1-11-9667 | 01 |   | BCBA | OTHER |